Predictors and Outcomes of Incident High Cholesterol in Adults on ART in South Africa

Abstract

Background: As the HIV-­‐infected population ages in sub-­‐Saharan Africa, non-­‐communicable chronic disease incidence among patients on ART is likely to rise. Specific antiretroviral drugs are considered independent risk factors for cardiovascular disease (CVD), and high total cholesterol (TC) is a risk factor for CVD, stroke and renal disease. We examined predictors of high TC in ART patients in South Africa.  Methods: Prospective study of HIV-­‐positive, ART-­‐naïve adults initiating ART at a large urban clinic in Johannesburg from 04/04 to 07/12. Patients with TC ≥6mg/dl at ART initiation were excluded. We defined incident high cholesterol as a TC ≥6mg/dl and categorized it as (i) one elevated TC, (ii) elevated TC with repeat TC <6mg/dl or (ii) elevated TC with repeat ≥6mg/dl. Cox regression was used to identify variables at ART initiation associated with incident high TC. Person-­‐time started at ART initiation and ended at the earliest of high TC, death, loss to follow up (LTF; >3 months late for next scheduled visit), transfer, completion of 24 months of follow-­‐up, or dataset closure (07/2014).  Results: Among 18,998 eligible patients, 2990 (16%) had a high TC by 24 months on ART. Of these, 488 (16%) had no repeat TC, 1323 (44%) had a repeat TC <6mg/dl, and 1179 (40%) had a persistently high TC ≥6mg/dl. Regression models showed patients ≥40 vs. <40 years, those with a CD4 count <100 vs. ≥ 100cells/mm3 or BMI ≥25 vs. <25kg/m2 at ART initiation had an increased hazard of high TC over the  first 24 months on ART (Table). Of the 2990 patients with a high TC, 5% died, 7% were LTF and 11% developed moderate or severe renal insufficiency (creatinine clearance <60ml/min). Among those with a repeat TC, rates of mortality (0.82 vs. 0.83/100pys) and LTF (6.1 vs. 7.3/100pys) after high TC were  similar for those with incident high TC and a repeat TC <6mg/dl compared to those with a persistently high TC ≥6mg/dl. However, those with persistently high TC ≥6mg/dl had a higher rate of renal insufficiency (CrCl <90ml/min) (19.0/100pys) after high TC co mpared to those who reduced their TC <6mg/dl (16.0/100pys). 31% of patients with a high TC changed a single drug, mainly from d4T to TDF or ABC, while 29% were prescribed cholesterol lowering drugs and 13% had both.  Conclusions: Older patients, those on stavudine, those overweight or with low CD4 counts should be targeted for frequent TC monitoring and identification of other risk factors of CVD in order to implement lifestyle modifications and pharmaceutical therapy.

Conference: CROI 2015, Seattle, Washington, USA