Highly active antiretroviral therapy (HAART) may induce dyslipidemia, insulin resistance and body fat distribution similar to that seen in the metabolic syndrome. Hypertension is often a part of the classic metabolic syndrome, but few studies are published about hypertension in HIV-positive patients on HAART. The aim of this study was to compare the prevalence of hypertension in HIV-positive patients on HAART with that in HIV-positive/HAART-naïve patients and HIV-negative controls. The cross-sectional study included 283 unselected HIV-positive ambulatory patients, 219 who were on HAART and 64 who were HAART-naïve. Age- and gender-matched controls (n=438) were randomly selected from a simultaneous health survey of the general population. The prevalence of hypertension was 21% in patients on HAART, 13% in HAART-naïve patients (P=0.20), and 24% in HIV-negative controls (P=0.28). Among several possible risk factors for hypertension, only body mass index (BMI) was found to be a confounder. BMI was similar in HAART-treated and HAART-naïve patients but elevated in controls compared to HAART-treated patients. After adjustment for BMI, the prevalence of hypertension in HIV-negative controls was slightly lower than that in patients on HAART (P=0.29). The results demonstrated a prevalence of hypertension in patients on HAART similar to that in HIV-negative controls. The prevalence of hypertension was somewhat higher in patients on HAART compared to HAART-naïve patients, but the difference was not statistically significant. Considering the marked drop in mortality following antiretroviral therapy, we conclude that the possible influence of HAART on the prevalence of hypertension appears to be a minor problem.

ObjectivesFacial lipoatrophy can be devastating for HIV-infected patients, with negative effects on self-esteem. In this study, we treated facial fat atrophy in the nasogenian area with hyaluronic acid (Restylane SubQ; Q-Med AB, Uppsala, Sweden). MethodsTwenty patients were included in the study. Treatment effects were evaluated at baseline, and at weeks 6, 24 and 52 using ultrasound, the Global Aesthetic Improvement Scale, the Visual Analogue Scale and the Rosenberg Self-Esteem Scale. ResultsMean (AE standard deviation) total cutaneous thickness increased from 6 AE 1 mm at baseline to 15 AE 3 mm at week 6 (Po0.001), and declined to 10 AE 2 mm at week 52 (Po0.001 vs baseline). The response rate (total cutaneous thickness 410 mm) was 100% at week 6, 85% at week 24 and 60% at week 52. At week 6, all of the patients classified their facial appearance as very much improved or moderately improved. They also reported increased satisfaction with their facial appearance and had higher self-esteem scores. At week 52, 15 of 19 patients still classified their facial appearance as very much improved or moderately improved, although the mean total cutaneous thickness had gradually declined. ConclusionsOur results indicate that Restylane SubQ is a useful and well-tolerated dermal filler for treating HIV-positive patients with facial lipoatrophy.

Increased coronary heart disease risk in HIV-positive patients using antiretroviral therapy (ART) has been a controversial topic since 1998 when the dyslipidaemic effect of protease inhibitors (PIs) was recognised. Accumulating evidence suggests an association between ART and increased coronary heart disease risk. In 2003, the large, prospective D:A:D (Data Collection on Adverse Events of Anti-HIV Drugs) study reported a 26% relative increase in the rate of myocardial infarction per year of exposure during the first 4-6 years of use. As the HIV-population grows older, infectious disease specialists have to consider unfamiliar areas of internal medicine such as lipid-lowering therapy and smoking cessation. Moreover, the ART regimen itself may be a modifiable risk factor, as there are both class differences and within-class differences in the tendency to increase lipids. Most nucleoside reverse transcriptase inhibitors (NRTIs), including the newer agents tenofovir disoproxil fumarate and emtricitabine, have little or no effect on lipid levels or glucose metabolism. One exception is the highly effective NRTI stavudine, which has a dyslipidaemic profile and a negative effect on glucose metabolism. In contrast the non-nucleoside reverse transcriptase inhibitor nevirapine may increase the 'good cholesterol' high-density lipoprotein (HDL) cholesterol and thus reduce the total cholesterol : HDL cholesterol index. Most of the PIs have some dyslipidaemic effect, especially ritonavir (alone or in combination with other PIs), fosamprenavir and the novel PI tipranavir. Only atazanavir, and to some extent saquinavir, seem to have little effect on lipid levels and glucose metabolism. Studies on blood pressure in HIV-positive patients have been contradictory. Apart from a recent report from the D:A:D study where lower blood pressure was found in patients receiving NNRTIs, the influence of the individual drugs on blood pressure is unknown. When hypertension is detected in a HIV-positive patient, creatinine clearance (CL(CR)) should be calculated and the urine checked for proteinuria. When CL(CR) is <30 mL/min, tenofovir disoproxil fumarate is not recommended. Many hypertensive HIV-positive patients have proteinuria and an ACE inhibitor or an angiotensin II receptor antagonist is a better choice than a thiazide diuretic or calcium channel antagonist in these patients. In addition, physicians treating patients with ART should be especially aware of the long list of possible interactions between PIs and anti-hypertensive- and lipid-lowering drugs. This review discusses important clinical aspects of treating middle-aged HIV-positive patients who have an increased risk of experiencing a cardiovascular event.

The aim of this study was to compare the prevalence of metabolic syndrome and insulin resistance in HIV-positive patients with and without HAART and healthy HIV-negative controls. In total 357 subjects were examined: 56 HIV-positive HAART-naïve, 207 HIV-positive on HAART treatment and 94 HIV-negative controls. We measured blood pressure, abdominal circumference, weight and height, and fasting serum levels of glucose, insulin and lipids in all the subjects. The presence of lipodystrophy was assessed in the HAART-treated patients. In non-overweight subjects the prevalence of the metabolic syndrome was 15% (25 of 162) in HAART-treated patients, 2% (1 of 44) in HAART-naïve (p=0.019) and 2% (1 of 45) in controls (p=0.020). The prevalence of insulin resistance in non-overweight subjects was also higher in HAART-treated than in controls, 39% vs 18% (p=0.012) but similar to HAART-naïve, 32% (p = 0.48 vs HAART, p = 0.22 vs controls). In non-overweight patients with lipodystrophy the metabolic syndrome was diagnosed in 21% and insulin resistance in 49%. In the entire HAART group 25% had the metabolic syndrome and/or insulin resistance without having lipodystrophy. We conclude that fasting glucose, HDL-cholesterol, triglycerides and blood pressure should be closely monitored in all HAART-treated patients, not only in overweighed or lipodystrophic individuals.

BackgroundThe main objective of this study was to describe the patients who were hospitalised at Oslo University Hospital Aker during the first wave of pandemic Influenza A (H1N1) in Norway.MethodsClinical data on all patients hospitalised with influenza-like illness from July to the end of November 2009 were collected prospectively. Patients with confirmed H1N1 Influenza A were compared to patients with negative H1N1 tests.Results182 patients were hospitalised with suspected H1N1 Influenza A and 64 (35%) tested positive. Seventeen patients with positive tests (27%) were admitted to an intensive care unit and four patients died (6%). The H1N1 positive patients were younger, consisted of a higher proportion of non-ethnic Norwegians, had a higher heart rate on admission, and fewer had pre-existing hypertension, compared to the H1N1 negative patients. However, hypertension was the only medical condition that was significantly associated with a more serious outcome defined as ICU admission or death, with a univariate odds ratio of the composite endpoint in H1N1 positive and negative patients of 6.1 (95% CI 1.3-29.3) and 3.2 (95% CI 1.2-8.7), respectively. Chest radiography revealed pneumonia in 24/59 H1N1 positive patients. 63 of 64 H1N1 positive patients received oseltamivir.ConclusionsThe extra burden of hospitalisations was relatively small and we managed to admit all the patients with suspected H1N1 influenza without opening new pandemic isolation wards. The morbidity and mortality were similar to reports from comparable countries. Established hypertension was associated with more severe morbidity and patients with hypertension should be considered candidates for vaccination programs in future pandemics.

This is the first study where HIV-associated body composition changes are described in a Scandinavian cohort. All HIV-positive patients living in Oslo who attended our outpatient clinic (n = 407) were invited to participate. 308 patients (78%) were included. Lipodystrophy (LD) prevalence was 37.3% in patients on antiretroviral therapy (ART+) compared to 10.9% in patients without ART (p < 0.001). Prominent veins and combined fat atrophy/accumulation were exclusively found in the ART+ group. Determinants of prominent veins were skin fold thickness, duration of nucleoside reverse transcriptase inhibitor treatment, duration of protease inhibitor treatment and current use of stavudine. When patients with and without LD were compared, breast circumference was 10.6 cm larger in LD+ women than in LD- women (p = 0.003). Chest pain was reported in 26.5% of LD+ compared to 3.9% (p < 0.001) of LD- patients. This may be associated with an increased level of creatin kinase in LD+ compared to LD- patients (161 +/- 179 U/I vs 102 +/- 68, p = 0.004). Eight years after HIV diagnosis 59.1% of the patients with LD had a regular job and 59.4% reported no or small problems with ART.

Our objective was to compare the prevalence of high-density lipoprotein-cholesterol (HDL-c) level < 1 mmol/L in non-nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI) recipients in an unselected HIV-positive population. All HIV-positive patients living in Oslo who attended our outpatient clinic from April 1, 2000 to April 1, 2001 were invited to a study of cardiovascular risk factors. In this substudy, 40 NNRTI recipients and 124 PI recipients were included. Prevalence of HDL-c <1 mmol/L was 7.5% in the NNRTI recipients compared with 35.5% in the PI recipients (P <0.001). In the multivariate analyses, use of NNRTI was a significant protective factor (odds ratio [OR] 0.17; 95% confidence interval [CI] 0.05-0.66; P = 0.01) and elevated triglycerides a significant risk factor (OR 3.40; 95% CI 1.47-7.86; P = 0.004) for low HDL-c level. Our study shows that NNRTI recipients have a more favourable HDL-c profile than PI recipients, even when possible confounding factors are taken into account.

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