HIV Infection in the Era of Highly Active Antiretroviral Treatment and Some of Its Associated Complications 2 2 . Dyslipidemia and antiretroviral therapy

Changes in lipid profile, like increased serum triglycerides (TG) and decreased cholesterol levels have been described in patients with HIV infection before the introduction of highly active antiretroviral therapy (HAART) (Constans et al., 1994; Grunfeld et al., 1991; Shor-Posner et al., 1993). However, with the widespread use of HAART it has been worsening. After the introduction of protease inhibitors (PIs) in 1996, patients developed a syndrome of fat redistribution with peripheral loss and central gain, generally associated with metabolic abnormalities and insulin resistance (lipodistrophy syndrome) (Carr et al., 1998). High levels of TG and total cholesterol (TC) concentrations are well known and often associated with abnormal body fat distribution and glucose metabolism disturbs (Carr et al., 1998). On persons treated with HAART, TG and TC elevations are associated with the use of protease inhibitors/nonnucleoside reverse transcriptase inhibitor (PIs/NNRTI) regimens (54 and 44% respectively), followed by PIs regimes (40 and 27% respectively) and NNRTI-containing combinations (32 and 23% respectively) (Friss Moller et al., 2003). All these symptoms are related to metabolic syndrome that could act to increase the cardiovascular risk in HIVinfected patients. Another aspect of these metabolic alterations is non-alcoholic fatty liver disease. Its prevalence is higher in HIV infected patients (30-40%) than in general population (14-31%) (Crum-Cianflone et al., 2009; Guaraldi et al., 2008). It is believed that there is a potential role of the antiretroviral therapy in the pathology of non-alcoholic fatty liver disease due to its negative effects on glucose control, lipid metabolism, body fat redistribution, insulin resistance and mitochondrial toxicity (Crum-Cianflone et al., 2009; Guaraldi et al., 2008). HAART has change dramatically the natural history of HIV-infection, leading to a notable extension of life expectancy and decline in mortality (Palella et al., 1998). Thus, mortality rates in HIV-infected patients who have experienced a CD4 recovery (> 500 cells/mm3) on long-term treatment resemble that of the general population (Lewden et al., 2007). However, prolonged metabolic imbalances could act on the long-term prognosis and outcome of HIVinfected persons. There is an increasing concern about the cardiovascular risk in this population despite the virological control (Graham, et al., 2000; Manfredi et al., 2000; Palella et al., 1998). Cardiovascular disease is emerging as one of the most important co morbidity and cause of death (Sackoff et al., 2006). Early identification and proper management of traditional cardiovascular risk factors, such as smoking, overweight or hypertension is imperative (Barbaro, 2006; Triant et al., 2007). As the prevalence of metabolic disorders is age-related their incidence will increase as HIV population becomes older (Triant et L., 2007). Thus, active prevention, together with prompt diagnosis and management of cardiovascular risk factors must be integrated on the routine of HIV care.