Beruflich Dokumente
Kultur Dokumente
version 3.5.1,
(18)
except for
Cohens kappa index, determined through an online
calculator.
(19)
Results
One hundred and fourteen outpatients from Hospi-
tal Dr. Enrique Garcs HIV/AIDS Clinic were included in
this research. Characteristics of the sample are shown
in table 1. Thirteen patients (11.4%) were nave, and
101 (88.6%) were HAART-experienced. Of those in-
dividuals currently under PI at the time of the study,
63.3% (n=19) had been taking such drugs for longer
than twelve months.
One or more features of the MS were seen in
103 (90.25%) patients. The most common triad was
hypertriglyceridemia, abdominal obesity and low HDL-c
(n=25). Frequency of metabolic abnormalities associa-
ted with the MS is represented in table 2.
Prevalence of the MS in the sample was 35.1%
(n=40) when using ATP III criteria and 29.8% (n=34)
according to IDF. Prevalence in men was 26.9% (n=18)
and 19.4% (n=13), respectively. In women, it was
46.8% (n=22) and 44.7% (n=21). Concordance betwe-
en these two denitions, calculated with Cohens kappa
coefcient () was 0.88, with a standard error of 0.09.
Table 3 shows demographic, anthropometric and HIV-
related variables in patients with and without the MS.
MS prevalence showed a direct relationship with
age, increasing from 18.4% in the 18-to-30-years
age group to 57.1% in individuals 51 years of age
and older. Mean age was higher in patients diagno-
sed with MS according to ATP III and IDF criteria as
compared to those who did not have it. Nevertheless,
the results were statistically signicant only for the
former (p=0.0092).
Among patients on HAART, 36.6% were diagnosed
with MS using ATP III criteria and 30.7% according to
IDF. When comparing HAART-experienced with nave
individuals, we found that the former were signi-
cantly older (37.8 11.68 vs. 28.69 5.41 years,
p=0.0029) and their triglyceride levels higher (220.00
128.39 vs. 133.53 63.15 mg/dL, p=0.0068).
Mean glycemia was found to be more elevated in
16
Rev Panam Infectol 2011;13(2):12-18. Rev Panam Infectol 2011;13(2):12-18.
patients on HAART (94.80 17.77 vs. 85.62
10.58 mg/dL, p=0.06) and, as opposed to what was ex-
pected, HDL-c readings were signicantly higher in ma-
les who receive such drugs (42.22 15.3 vs. 31.12
9.09 mg/dL, p=0.05).
The only statistically signicant difference found
when comparing patients currently receiving PI for
more than twelve months with nave individuals or tho-
se taking them for shorter periods was triglyceridemia,
markedly higher in the former (293.21 199.25 vs.
193.53 98.42 mg/dL, p=0.0120).
An unconditional logistic regression analysis model
was performed in order to assess the effect of indepen-
dent variables on MS diagnosis. The only ones found to
be signicant and independently associated with the
MS were age older than 30 years [OR 3.16 (1.15-8.7),
p=0.02] and overweight, dened as a BMI > 25Kg/m
2
[OR 5.65 (2.17-14.73), p=0.0004].
Discussion
Prevalence of the MS in our sample was found to be
higher than that reported by other studies, which varies
between 14 and 26% according to ATP III criteria.
(20-27)
It should be noted that the 2005 ATP III criteria
employed in our research
(15)
agree with the 2009
consensus recommendation
(14)
of using the same WC
cutoff points suggested for Southeast Asians in Ethnic
Central and South Americans (> 80 cm in women and
> 90 cm in men) until more data are available.
MS occurrence among males from our sample did
not differ much from that reported in international
studies with HIV-positive populations;
(20,24)
however it
was markedly higher in women. Such ndings could be
explained by the higher frequency of MS in Hispanic
women as compared to other ethnic groups found in
general population studies. Ford et al.
(28)
reported a
MS prevalence of 20.5% in Mexican-American males
and 35.5% in females. Prevalence among males was
similar to that among Caucasians; however, it was sig-
nicantly higher in Mexican-American women than in
any other ethnic group. Similar ndings were published
by Park et al.
(29)
The higher predisposition to developing MS seen
in women could be due to biologic, psychological and
environmental factors. The higher percentage of body
fat in females determines lower energy expenditure per
kilogram. Some studies have also found an association
between the number of pregnancies and obesity
(30)
.
Moreover, menopause has an adverse effect on body
composition and metabolic parameters, leading to an
increased likelihood of developing obesity.
(31)
Psycho-
logical factors can be either a cause or a consequence
of obesity, and females are known to have a higher
frequency of eating disorders.
(32)
Finally, environmental
factors could also play a role in women, because the
portions they eat are often larger than their needs, since
their energy requirements are lower than mens due to
their phenotype and level of activity.
(30)
CARMELA,
(11)
the only PubMed-indexed research to analyze the pre-
valence of MS in an Ecuadorian general population,
found MS to be present in 7.5% of males and 20.1%
of females, which corroborates womens tendency to
develop such anomalies. However, CARMELA employed
WC cutoff points suggested for Caucasians and glyce-
mia higher than 110mg/dL as criteria for dening MS,
which could lead to underdiagnosis. Anyway, given
the evidence of an increased likelihood of developing
metabolic anomalies, Hispanic women should be
particularly targeted for their early identication and
management.
It seems to be that prevalence of the MS is higher
among HIV-infected individuals as compared to the
general population in Ecuador. However, more studies
with standardized denitions are needed in order to
verify this assertion.
Tobacco use did not show an association with
the development of MS in our sample, nor in other
studies.
(20,21,24)
After unconditional logistic regression analysis was
carried out, only age older than 30 years and overweight
(BMI > 25 Kg/m
2
) were signicant and independently
associated with the development of MS. These results
are similar to those reported by Jeric et al. in a study
with 710 HIV-positive Spanish patients.
(20)
Even though
the relationship between overweight and MS would
seem quite obvious, age is not always taken into ac-
count as a risk factor. Therefore, both identication and
control of metabolic anomalies become fundamental
as patients grow older.
Concordance between ATP III and IDF criteria
was almost perfect,
(33)
with =0.88. This value is
comparable to that reported by Guerrero-Romero
(34)
in
a Mexican general population study (=0.873), but
differs from the moderate concordance found by Sa-
maras et al.
(24)
in HIV-infected individuals (=0.46). It
should be noted that we employed the same WC cutoff
points as Guerrero-Romero, while Samaras used those
recommended for Caucasians. Since this parameter is
mandatory in the IDF denition for the MS, the lower
the WC required the higher the concordance will be.
Our ndings suggest that ATP III and IDF criteria are
equally valid for the diagnosis of MS in Hispanics.
Variables such as current CD4
+
cell count and time
since the diagnosis of HIV infection was made were
not signicantly associated with the presence of MS
in our research or in Jerics.
(20)
Samaras
(24)
did nd a
statistically signicant relation between the duration of
HIV infection and the development of metabolic ano-
17
Villamar MF, Albuja AC Mctabolic syndromc among HIV-infcctcd out...
malies, probably due to the more prolonged use of ART.
Among patients from Hospital Dr. Enrique Garcs
HIV/AIDS Clinic, detectable viral load values were
inversely related to the presence of MS [OR 0.27
(CI 95% 0.09-0.79), p=0.0058]. Similar ndings
were reported by Estrada et al.,
(35)
while three other
studies
(21,36,37)
found no signicant association between
both variables. This can be explained by the use of
HAART, which increases the risk of presenting meta-
bolic anomalies while decreasing viral replication rate.
Since HAART, especially when containing PI, is a
known predisposing factor to developing MS, it is likely
that a statistically signicant association between these
two variables could have been found if the sample size
were larger. Given the high prevalence of MS among
Hispanics, it is also possible that it was present in some
patients prior to the initiation of HAART.
Many of the metabolic anomalies seen in HIV-
infected individuals are often attributed to HAART.
Cohort studies have demonstrated that PI use is
associated with the development of dyslipidemia and
other metabolic disorders,
(38)
particularly signicant
elevations in serum cholesterol and triglycerides.
(39-41)
In our study, individuals currently under PI for twel-
ve months or more were found to have signicantly
higher triglyceridemia as compared to nave patients
or those who received PI for shorter periods (293
199 vs. 194 98mg/dL, p=0.0120).
When HDL-c levels were analyzed, signicantly
higher values were found in male individuals on HAART
versus naves. Such ndings could seem paradoxical,
because PI-based schemes tend to reduce HDL-c
levels.
(39-41)
However, use of non-nucleoside reverse
transcriptase inhibitors (NNRTI) has been reported to
decrease the risk of having low HDL-c
(8,41,42)
and since
78.2% (n=79) of patients on HAART at Hospital Dr.
Enrique Garcs are under efavirenz-containing sche-
mes, these results can be justied.
Even though the difference between serum glucose
means in HAART-experienced and nave individuals was
not statistically signicant (p=0.06), it does correlate
with ndings reported in other studies which show a
predisposition to higher glucose levels in the latter.
(43,44)
The results of our research suggest that tradi-
tional risk factors are more strongly associated with
the development of the MS in HIV-positive Hispanic
individuals than those related to the virus itself and
HAART. Therefore, timely diagnosis and management
of metabolic disorders, emphasizing the importance
of healthy lifestyles, are key issues in this population.
Acknowledgements
The authors would like to thank Dr. Rosa Polo,
M.D., PhD (Plan Nacional Sobre el SIDA, Madrid,
Spain) and LCDR Matthew T. Brigger, M.D., M.P.H.
(Naval Medical Center San Diego Department Of Oto-
laryngology Head and Neck Surgery, San Diego, CA,
U.S.A.), for reviewing the Spanish and English versions
of this manuscript, respectively.
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Correspondence:
Dr. Mauricio Fernando Villamar
125 Nashua St. 7
th
Floor, Room 726.
Boston, MA, U.S.A.
e-mail: mvillamar@neuromodulationlab.org
Rev Panam Infectol 2011;13(2):12-18.