1. Cholesterol Management in HIV-infected and Uninfected Patients: The Veterans Aging Cohort Study
Leaf, DA, Goulet J, Goetz MB, Oursler KA, Gilbert C, Frieberg M, Rodriguez-Barradas M, Butt, A, Justice A.

2. The Purpose of the Study:
To compare the rate of treatment of hypercholesterolemia among HIV + and HIV – patients according to treatment guidelines
To explain differences in treatment in the two groups based on age, transaminitis, CAD and CAD risk factors, ART, HCV infection, viral load and CD4 cell levels

3. ATP III LDL-cholesterol goals for drug therapy in different risk categories
Class I
CHD or CHD risk equivalent (DM, AAA, CVA, PAD, and 10-year risk >20 percent)
LDL-cholesterol > 130 mg/dL
Class II
≥ 2 risk factors (HTN, Age, HTN, smoking,  HDL- C)
LDL-cholesterol > 160 mg/dL
Class III
≤ 1 risk factor
LDL-cholesterol > 190 mg/dL
Adapted from Adult Treatment Panel III at

4. Demographic and clinical characteristics
HIV-infected (926)
Uninfected (651) p
Age (Mean ± SD)
49.7 ± 8.8 years
55.8 ± 9.9 years
<0.01
Ethnicity
White (%)
27.9%
37.4%
African-American (%)
53.5%
43.4%
Latino (%)
11.7%
11.9%
Other (%)
6.6%
7.0%
AUDIT Score (Mean ± SD)
3.8 ± 5.5
3.8 ± 5.2
0.85
Current Cigarette Smoking (%)
45.1%
35.0%
Lipid Profile (mean ± SD)
Total cholesterol
208 ± 55.3 mg/dL
209.0 ± 42.3 mg/dL
0.94
LDL-cholesterol
126.0 ± 42.9 mg/dL
133.5 ± 36.3 mg/dL
HDL-cholesterol
45.9 ± 14.9 mg/dL
46.0 ± 12.6 mg/dL
0.87
Triglycerides
305.3 ± g/dL
225.8 ± g/dL
LDL-cholesterol criteria for Rx *
27.8%
33.6%
0.01
Transaminitis** (%)
42.7%
13.1%
BMI >30 (%)
15.7%
41.4%
Diabetes mellitus (%)
35.8%
37.7%
0.43
Alcohol abuse (%)
23.6%
17.9%
Coronary artery disease (%)
5.3%
17.4%
Cerebrovascular disease (%)
1.9%
2.1%
0.77
Antihypertensive medications (%)
45.7%
54.3%
TABLE 1. Comparison of demographic and clinical characteristics between HIV-infected and uninfected VACS participants
* These are based upon CAD-risk based LDL-C treatment guidelines.
** transaminitis: AST or ALT > 2 X upper limit of normal

5. NCEPT III CAD risk factor status
HIV-Infected
HIV-Uninfected
CAD risk factor
Cigarette smoking
45.1%
35.0%
<0.01
Hypertension
45.7%
54.3%
 HDL cholesterol
36.0%
33.1%
0.24
Age over 45 years
71.0%
88.0%
CAD risk factors
9.0%
4.0% 1
27.4%
21.6% 2
37.3%
40.5% 3
22.3%
26.5% 4
3.7%
7.1%
Mean ± SD
1.8 ± 1.0
2.1 ± 1.0
Distribution of CAD risk factor status according to NCEPT III CAD risk factor status criteria

6. Proportion of patients receiving lipid lowering medications, by HIV status
HIV-infected
Uninfected
N (%) p
Any medication
15.4%
37.9%
<0.01
Atorvastin*
9.8%
6.9%
0.31
Lovastatin
6.3%
17.8%
Pravastatin
56.7%
0.1%
Simvastatin
31.5%
80.2%
Nicotinic acid
7.7%
10.1%
0.42
Cholestryramine

7. Treatment of patients meeting LDL criteria for receipt of lipid lowering therapy, by HIV status
HIV-infected
HIV-Uninfected
N (%) p
Met LDL criteria
257 (27.8%)
219 (33.6%)
0.01
Treated*
101 (39.3%)
135 (61.6%)
<0.01
Proportion of patients meeting LDL-cholesterol criteria
for receipt of lipid and who received treatment, by HIV status.
* among those who met criteria
* among those who met criteria for treatment

8. Associations with lipid lowering Rx – all pts
Odds ratio (95% C.I) p
HIV infection (yes/no)
0.44 ( )
<0.01
Hepatitis C viral infection
0.44 ( )
0.02
Age (continuous)
1.04 ( )
Ethnicity (compared with white)
Black
1.04 ( )
0.84
Hispanic
1.10 ( )
0.69
Other
0.56 ( )
0.09
Transaminitis
1.28 ( )
0.29
CAD risk group **
CAD
1.68 ( )
0.03
Non-CAD: Med risk
0.91 ( )
0.71
Treatment site (compared to E) A
1.45 ( ) B
0.68 ( ) C
0.81 ( ) D
1.15 ( )
Table 5. Results of Generalized Estimating Equation (GEE)
analysis of the association between HIV status and receipt of lipid
lowering medications, controlling for patient and treatment
characteristics, among patients who met LDL criteria for treatment (n=476).
*GEE analysis clustered on site of care
**compared non-CAD: low risk

9. Associations with lipid lowering Rx – HIV only
Odds ratio (95% C.I) p
Hepatitis C viral infection present
0.34 ( )
<0.01
Age (continuous)
1.07 ( )
Ethnicity (compared with white)
Black
1.51 ( )
0.23
Hispanic
1.98 ( )
0.19
Other
1.88 ( )
0.09
Transaminitis present
1.69 ( )
0.06
CAD risk group*
CAD
0.97 ( )
0.92
Non-CAD: Med risk
0.65 ( )
0.25
Treatment site (compared to E) A
2.05 ( ) B
0.63 ( ) C
0.58 ( ) D
1.56 ( )
Serum CD4 levels
1.00 ( )
0.12
Log viral load
0.57 ( )
HAART
0.89 ( )
0.41
Results of Generalized Estimating Equation (GEE) analysis of the association between
transaminitis and receipt of lipid lowering medications among HIV-infected veterans meeting
LDL criteria for treatment, controlling for other demographic and clinical characteristics (N=257)
*compared non-CAD: low risk
Interpretation of Findings in Combined Groups

10. Summary of Findings
61.6% hypercholesterolemic HIV- (68% CAD, 50% non-CAD) and 39.3% HIV+ (42% CAD, 33% non-CAD) were treated.
Both Groups: less likely treated; HVC+, more likely treated; Older Age and CAD+.
HIV+ only: less likely treated; HCV+ and high log viral load, more likely treated; older age.
HIV+ had site differences in treatment

11. Interpretation of Findings in Combined Groups
HIV+ are 44% less treated:
‘learning curve’ for HIV providers
variable responsibility for managing ‘primary care issues’
‘ switch the offending drug’ by HIV providers.
CAD+ (68% more) and older (4% more) patients: more likely recognized to be at higher risk.
HCV+ 44% less treated: i.) possible hepatotoxicity (but was not affected by transaminitis), ii.) perhaps treatment perceived less relevant in HCV+.

12. Interpretation of Findings in HIV+ Patients
HCV 34% less likely treated and older 7% more likely treated: previously discussed for both groups.
High viral load 57% less likely treated
 VL is surrogate for worse infection therefore lower priority to treat (but unlikely since lower CD4 counts not associated with decreased treatment)
VL is higher among less compliant patients
Reverse causality – providers are more likely to diagnose and treat lipids among ART recipients

13. Group Discussion