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Dyslipidemia is defined as abnormal concentrations of lipids, such as cholesterol and triglycerides, in the blood. Dyslipidemia disproportionately affects people living with HIV, and it is a major risk factor for cardiovascular disease. Fortunately, dyslipidemia can be reversed through lifestyle modifications and medication adjustments.
Dyslipidemia in HIV patients may be a direct result of the virus itself or a side-effect of antiretroviral therapies. When a person is first infected with HIV, their blood concentration of cholesterol tends to decrease while triglyceride levels often rise. Some antiretroviral therapies, especially protease inhibitors, have been associated with hyperlipidemia. When beginning therapy, HIV patients usually experience elevations in triglycerides and LDL-c, also known as "bad cholesterol." "Good cholesterol", or HDL-c, seems to be usually unaffected by antiretrovirals. More research is needed to know exactly why people living with HIV are more vulnerable to dyslipidemia.
Dyslipidemia is detected through laboratory testing of the patient's blood. Blood for analysis of lipid levels including total cholesterol and triglycerides should be collected after the patient has fasted for 8-12 hours. If possible, lipid levels should be tested soon after HIV diagnosis and before antiretroviral treatment begins. When starting antiretroviral medication, lipid levels should be monitored every 3-6 months. Once lipid levels stabilize, blood analysis should still be conducted once a year or more often if heart abnormalities manifest.
Lowering levels of LDL-c, or "bad cholesterol", is the primary goal of lipid-lowering treatment. The European Society of Cardiology has established guidelines for managing dyslipidemia, and they apply to HIV positive and HIV negative patients.
Behavioral recommendations for preventing and controlling dyslipidemia include:
-Reducing cholesterol and saturated fat consumption
-Increasing aerobic exercise
-Reducing alcohol intake
If lifestyle modifications are ineffective at controlling lipid levels, providers may consider changing the patient's antiretroviral medications. When changing an antiretroviral treatment regimen, patients should be closely monitored for side-effects related to new medications and for virological relapse.
If modifying the patient's antiretroviral treatment does not result in more acceptable lipid levels, providers can consider prescribing lipid-lowering agents; however, some drugs used to control lipids negatively interact with anti-HIV drugs, so careful consideration must be given to the risks of combining treatments.
Intensity of dyslipidemia prevention measures should be based on the patient's risk for cardiovascular disease. Tools for assessing a patient's likelihood of developing cardiovascular disease include the Framingham equation, PROCAM and the SCORE tool.