1. Methods Results Abstract No H-77 10 th CROI, Boston MA Contact information: Carlos del Rio MD* cdelrio@emory.edu David Rimland MD** David.Rimland@med.va.gov Jodie L. Guest PhD**Jodie.Guest@med.va.gov Ngoc-Anh Le PhD † ale@emory.edu Virgil Brown MD ‡ Virgil.Brown@med.va.gov Phone*: 404-616-7025 Fax*: 404-880-9305 Phone**: 404-728-7748 Fax**: 404-728-7782 Phone † : 404-321-6111 ext. 6899 Fax † : 404-728-4716 Lipid Abnormalities among PI-treated Women may be due to Excess Production of ApoC-III Isabel Hernández, Carlos del Rio, Erik Folch, Jeffrey Lennox, Ngoc-Anh Le, David Rimland, Jodie L. Guest, Virgil Brown. Emory University Center for AIDS Research, Emory Lipid Research Laboratory, & VA Medical Center. Atlanta, Georgia, USA VariableNPercentage Race: African-American18089 White or Hispanic2211 Age > 40 years10652 Tobacco +8643 High Blood Pressure*5427 Diabetes Mellitus168 BMI Normal6130 Overweight13667 Lipid-lowering drugs2010 Family history of: DM9848.5 Stroke8140.1 CVD7848.6 CD4 >200 cells/ mL15074 VL <10,000 copies/ mL13265 VL < 400 copies/ mL9145 Table 1. Patient Characteristics (N=202). Abstract Background: Mortality from AIDS has been reduced with the availability of HIV-protease inhibitors (PI); however, lipid abnormalities have become common among PI-treated patients and may lead to premature atherosclerosis and its complications. The pathogenesis of these abnormalities is not well understood. We studied the prevalence of lipid abnormalities as well as apolipoproteins (new markers of coronary artery disease) among HIV- infected women in an inner city clinic in the US. Methods: Cross-sectional study of HIV-infected women who had: 1) >3 months of stable ARV therapy; 2) no ARV therapy in the last 3 months or, 3) who were treatment naïve. A questionnaire and a complete fasting lipid profile were performed. Laboratory and medical records were reviewed. Comparisons were made using Chi-Square, Fisher’s Exact test or t test as appropriate. Results: 202 HIV-infected women were included between 3/02 and 10/02. The majority were African American (90%), with median age of 41 years (range 21-72); 8% were diabetic, 43% smoked, 10% were on anti-lipid drugs, and 67% were overweight. Mean CD4 count was 371 cells/µL (median 323, range 11- 1123) and mean viral load was 61,153 copies/mL (median 1,070, range 30- >750000). Half of the patients had a viral load 50 copies/mL. Two thirds (131/202) had received ARVs for at least 3 months, 26% (52) had no ARV therapy in the last 3 months and 9% (19) were naïve. Among those receiving ARVs (131), 66% (86) were on a PI (NFV 55%, LPV/rtv 30%, IDV 12%, RTV 8%) and 35% were on an NNRTI together with reverse transcriptase inhibitors (d4T in 30% and ddI in 26%). See tables 2 and 3. Conclusions: Our data suggest that among PI- treated women, lipid abnormalities seem to be related to excess of ApoC-III in VLDL which can interfere with normal triglyceride hydrolysis. These drugs may be causing an increased production of ApoC-III which can lead to all of the observed lipoprotein abnormalities described. Background Conclusions GroupN (%) Chol >240 TG >200 HDL <35 LDL >160 Apo A-I < 80 Apo B >120 ApoC-III >25 Apo E <4 Overall20213.016.822.39.48.425.730.213.4 PI86 (42.6)20.9 †18.611.6 ‡16.3*8.134.9 †41.9 ‡3.5 † No PI45 (22.3)13.320.013.3 †2.2 28.9 *35.6 †15.6 No ARV/ naïve 71 (35.1)2.812.740.85.612.7 23.9 * p<0.05 † p≤0.01 ‡ p≤0.0001 Statistical significance is based on comparisons with the “No ARV/ naïve” group. VAMedicalCenter GroupN (%) Chol >240 TG >200 HDL <35 LDL >160 Apo A-I <80 Apo B >120 Apo C-III >25 Apo E <4 PI with hyperlipidemia 26 (30) 69.2 ‡61.5 ‡7.742.3 ‡15.461.5 †80.8 ‡0.0 PI with normal lipid profile 60 (70) 0.0 13.35.0 23.3255.0 Group N (%) Chol >240 TG >200 HDL <35 LDL >160 Apo A-I <80 Apo B >120 Apo CIII >25 Apo E <4 PI 72 (35.6) 19.4†19.412.5†15.38.336.1†43.1‡4.2† PI and NNRTI 14 (6.9) 28.6†14.37.1*21.47.128.635.7*0 NNRTI 32 (15.8) 15.6*25.06.2†0.03.134.4*43.7†15.6 Only NRTI 13 (6.4) 7.7 30.87.70.015.4 No ARV in last 3 months or naïve 71 (35.1) 2.812.740.85.612.7 23.9 Study design: Cross-sectional study Patient population: HIV infected patients with advanced disease, divided in 3 groups 1) Three months of stable ARV therapy 2) No ARV therapy in the last 3 months 3) Treatment naïve Setting: Infectious Diseases Program (IDP) at Grady Memorial Hospital (GMH) in Atlanta GA, USA. Enrollment: Between 3/02 and 10/02, at routine blood drawn, if the patient was fasting and willing to participate. Procedure: Questionnaire and fasting lipid profile. Medical and laboratory records were reviewed. Hyperlipidemia: Cholesterol >= 240 and / or Triglicerides >= 200 (according to the high risk categories of the National Cholesterol Education Program III Guidelines). Biomarkers assessed: Basic lipid profile (TG, total, HDL, and direct LDL cholesterol); Apo-lipoprotein risk profile (Apo A-I, B, C-III, E, Lp(a)); Composition of TG-rich lipoproteins isolated at density <1.020 gm/mL by ultracentrifuge; and LDL phenotype by non-denaturating Gradient Gel Electrophoresis. Statistical analysis: Comparisons made with Chi- square, Fisher’s Exact test, t test, or Wilcoxon, using SAS software v.8.2. Previous studies using conventional lipid profile have not been consistent and potential abnormal pathways have not been identified. ApoC-III, which is present in Chylomicrons, VLDL (TG rich lipoproteins TRL), inhibits lipoprotein lipase in vitro and reduces VLDL and Chylo remnant clearance. Its over-expression would increase the TG concentrations and decrease TG clearance as demonstrated in mice transgenic for ApoCIII. Among PI-treated women, lipid abnormalities seem to be related to excess ApoC-III content of VLDL which can interfere with normal TG hydrolysis. Both, patients with PI or NNRTI therapy had  Elevated levels of total cholesterol,  Higher Apo C-III and Apo B levels  Higher levels of TG, however the percentage of patients with levels >200 mg/dL was not significantly different from patients with no ARV therapy. These findings suggest impaired metabolism of TG-rich lipoproteins. Additional risk factors of smoking and DM, in an aging population might increase the likelihood of future atherosclerotic events. Kinetic studies of apoC-III, apoB and triglycerides are planned to determine if the hypothetical physiologic alteration due to PI and NNRTI treatment is enhanced apoC-III synthesis. LPL LDL VLDL Cholesterol Ester Transport Protein TG Cholesterol Esters Fatty Acids LDL Receptor Remnant Receptor Excess apoC-III ChylomicronsRemnants Lipoprotein lipase LPL HDL Excess apoC-III Excess apoC-III Figure1. Potential Inhibitory Effects of the Excess Production of Apolipoprotein C-III. Two hundred and two HIV-infected women were included between 3/02 and 10/02. The median age was 41 years (range 21-72), mean CD4 count was 371 cells/mL (median 323), and mean VL was 61,153 copies/mL. Demographic and laboratory characteristics are shown in Table 1. Fig. 2. Patient Population. ARV Exposure. ARV >3m N=131 (65%) Median VL <400 No ARV last 3m N=52 (26%) Median VL 32,440 Naïve N=19 (9%) Median VL 59,350 Patient population N=202 Median viral load 1,070 copies/mL Figure 3. Current ARV exposure among patients with >3 months of therapy (n=131). Among those patients receiving ARVs (131), 86 (65.6%) were on a PI (NFV 54.6%, LPV/r 30.2%, IDV 11.6%, RTV 8.1%), and 35% were on NNRTI together with reverse transcriptase inhibitors. Simultaneous exposure to PI and NNRTIs occurred in 14 patients (10.7%). Median time of exposure to PI were 16 months and for NNRTIs 10 months. The most frequent regimens had AZT and 3TC with NFV (22/131 patients, 17%), with EFV (11, 8.4%), or with ABC (11, 8.4%). Parameter PI N=72 PI + NNRTI N=14 NNRTI N=32 Only NRTI N=13 No ARV/ naïve N=71 Mean Median Cholesterol 206.6 ‡ 201 212.9 † 197.5 198.8 † 190.5 161.5 153 161.1 163 TG 136.8 * 123 147.5 127 163.7 * 112 117.5 115 111.7 90 HDL 53.7 ‡ 51 55.9 † 53 52.4 ‡ 48 39.7 38 40.4 40 LDL 117.9 † 112 118.6 * 111 102.1 101.5 98.4 93 97.6 95 Apo A-I 151.9 ‡ 148 136.1 * 141 144.8 † 138 105.5 106 115.8 106 Apo B 109.7 † 96.5 102.9 91 105.6 * 107.5 73.6 67 85.6 77 Apo C-III 24.2 ‡ 24.2 23.6 † 23.1 23.7 † 21.2 19.5 18.9 19 17.8 Apo E 6.7 ‡ 6.4 7.3 † 6.3 6.0 5.4 4.9 4.3 5.2 5.0 We studied the prevalence of lipid abnormalities as well as apolipoproteins (new markers of coronary artery disease) among HIV-infected women in an inner city clinic in the US. * High blood pressure at the moment of the visit Table 2. Percentage of Women with Lipid Abnormalities. Table 3. Percentage of Women Exposed to PI (n=86) with and without Hyperlipidemia (cholesterol >240 and / or TG > 200 mg/dL). Table 4. Percentage of Women with Lipid Abnormalities by ARV Group Exposure. Comparisons made using Wilcoxon Rank sum test or t test. * p<0.05 † p<0.01 ‡ p<0.0001 Statistical significance is based on comparisons with the “No ARV/ naïve” group. Table 5. Mean Values of Lipids and Apolipoproteins by ARV Exposure Group. * p<0.05 † p<0.01 ‡ p<0.0001 Statistical significance is based on comparisons with the “No ARV/ naïve” group. In comparison with HIV + patients without treatment or treatment naïve, those patients being treated with ARV in the last 3 months had significant higher mean levels of cholesterol (199 vs 161 mg/dL), TG (143 vs 112), HDL, LDL and all the apolipoproteins tested (A- I, B, C-III, and E). Background An increase in LDL cholesterol and triglycerides (TG), as well as a decrease in HDL cholesterol are the lipid abnormalities associated with HIV infection and HAART. Other cardiovascular risk factors in HIV infected patients with HAART include: Increased visceral fat, insulin resistance, chronic inflammation and endothelial dysfunction / atherosclerosis. Acknowledgment: Partial support provided by the Emory CFAR (P30-AI50409). PI Lipid abnormalities Accelerated atherosclerosis and other complications Pathogenesis? * p<0.05 † p<0.01 ‡ p<0.0001 Statistical significance is based on comparisons with the “PI with normal lipid profile” group. Patients being treated with a PI were 7 times more likely to have total cholesterol >240 mg/dL (RR 6.9; 95%CI 1.6-29.3) in comparison with patients with no ARV. However, neither patients with PI, NNRTI nor both were more likely to have TG >200 mg/dL in comparison with patients with no ARV therapy (all 95%CI included the null value). Tables 4 and 5 shown the percentage of patients with lipid abnormalities, and the mean values by ARV treatment group. PI treated patients had higher levels of HDL, LDL and total cholesterol, and apoB, C-III and E (Table 2). The increase in Apo C - III levels was mainly present among patients with hyperlipidemia (Table 3).