HIV

• HIV is a viral infection which compromises immunity over time
• HIV


  • Characterised by low CD4 (less than 200) and detectable viral load
  • Physical manifestations: persistent fever/flu-like symptoms, sore throat, body rash, tiredness, joint/muscle pain, swollen lymph nodes
• Previously, the nutritional priorities for HIV patients were to prevent undernutrition and weight loss, but advancements in medical management of HIV means patients are living longer
• Over time, an increasing concern within the HIV population is the increased risk of cardiovascular disease
• Factors contributing to increased cardiovascular disease risk in HIV patients

  • Poor HIV control
  • Worsened immunity
  • Metabolic abnormalities
  • Lifestyle factors
• Atherogenic dyslipidaemia


  Increased formation of atherosclerotic plaques in vasculature
• Dyslipidaemia is common among HIV patients, and increases in dysfunctional subcutaneous fat and visceral fat increases rate of atherogenesis and therefore increases risk of conditions associated with this such as myocardial infarction, coronary heart disease and even stroke
• Management of lipid status may go some way in reducing rate of atherosclerotic plaque formation and therefore cardiovascular risk in people with HIV, making it a priority to target
• Investigation of strategies to manage hyperlipidaemia has been a complex task due to the different causes of dyslipidaemia
• Lipodystrophy - fat redistribution - is another issue that some HIV patients experience, therefore studies have to consider whether people with co-existing lipodystrophy would be investigated too
• Prevention


  Different methods both medical and dietary have been investigated to address hyperlipidaemia
• REPRIEVE study


  1. Randomised participants to daily pitvastatin or placebo

  2. Gave basic healthy eating and exercise advice annually

  3. Primary outcome was major CVD event

  4. Incidence of CVD events was much higher in the placebo group than statin group (hazard ratio 0.65)

  5. Trial had to be stopped early after a median of 5 years
• The REPRIEVE study suggests a significant reduction in incidence of CVD events in patients on statins vs placebo
• The REPRIEVE study involved participants with low to moderate risk of CVD, and lipid levels for inclusion were drawn up based on ASCVD risk score
• NICE guidance highlights that CVD risk tools may underestimate risk in HIV patients
• The REPRIEVE study found a greater reduction in LDL and non-HDL cholesterol in the trial group vs the placebo group at 12 months
• The REPRIEVE study is primarily focused on prevention as there were cut-off values where lipids could not be higher than a certain value, therefore it doesn't investigate the impact of statins on those already experiencing hyperlipidaemia
• Best Foods for your Heart study


  1. Investigated effect of Med Portfolio diet with low sat fat diet in people living with HIV experiencing dyslipidaemia

  2. Inclusion criteria was >3mmol/L LDL-C in stable HIV

  3. Randomised to either dietary advice of reducing saturated fat to <10% of energy intake or Mediterranean-style diet with cholesterol lowering foods (Portfolio, e.g. nuts, plant stanols, soy protein, soluble fibre)

  4. Primary outcome was attrition as this was a pilot study

  5. Other outcomes included diet quality/adherence to Med/Portfolio diets, and blood lipid profiles
• The Best Foods for your Heart study found that the Med-diet/Portfolio was feasible and showed greater improvement in diet quality and blood lipid profile compared to the low sat fat diet
• The Best Foods for your Heart study found that the diet scores in the Mediterranean diet and portfolio diets increased by a greater amount in the Med/Portfolio diet groups compared to low sat fat groups, however this was not sustained long-term
• The Best Foods for your Heart study found that participants had greater adherence to Mediterranean foods compared to portfolio foods, likely due to the differences between UK diets and Mediterranean diets/portfolio diets
• The Best Foods for your Heart study found that LDL-C at 6 months was lower in the intervention group compared to low sat fat group, and markers of CVD risk deteriorated over the 1 year follow up compared to markers improving in the intervention group over follow up
• The Best Foods for your Heart study was a pilot, so it is unclear whether the positive effects would remain on a larger scale, and the poor adherence long-term suggests that the diet may be difficult to adhere to, affecting long term outcomes
• The Best Foods for your Heart study excluded participants with lipid-affecting conditions, so it is unclear what proportion of the target group this excludes and whether this would impact the benefits of the intervention
• Lazzaretti et al 2012 study


  1. Investigated how dietary intervention in patients about to commence HAART affects lipid profile

  2. Intervention group received nutritional guidance on dyslipidaemia, based on the US National Cholesterol Education Program ATP III guidelines

  3. Control group received same baseline nutritional guidance with no guided follow-up

  4. Assessed lipid profile, BMI and waist-to-hip ratio before and every 3 months following
• The Lazzaretti et al 2012 study found that the intervention group had reduced total calories, cholesterol, % lipid and sat fat intake, stable BMI, stable LDL-C, decreased triglycerides, and reduced diagnoses of hypercholesterolaemia
• The Lazzaretti et al 2012 study shows that dietary intervention was able to maintain pre-HAART lipid profile, BMI, and improve diet quality
• The Lazzaretti et al 2012 study found that 70% of the control group were at risk of developing dyslipidaemia prior to commencing HAART, highlighting that there is a window of opportunity to prevent this
• The Lazzaretti et al 2012 study found that after 6 months there was no improvement in lipid profile, suggesting a plateau in effects long term
• A sub-study of the REPRIEVE trial in US participants found that atherosclerotic plaques were present in 50% of people, and even 30% of those with very low CVD risk, showing that as time progresses in HIV patients there is increased likelihood of atherosclerotic plaque formation
• The REPRIEVE trial suggests that preventative statin initiation may support positive outcomes and prevent dyslipidaemia more quickly, but guidelines are not recommending routine statin provision yet as more evidence is likely needed to confirm lack of adverse effects
• The evidence is proving that dietary interventions are successful in improving lipid profile and that adherence is good, but more concrete evidence investigating primary outcomes of lipid profile, diet quality and outcomes is needed
• The use of a prescriptive diet which varies greatly from usual dietary patterns in the UK may make adherence more difficult, so the best dietary intervention would need to consider how to encourage adherence and long term improved outcomes
• The key strength of the Lazzaretti et al 2012 trial was the regular support of a dietitian which may have improved adherence, and the more open guidelines used (US NCEP ATP III) which allowed for more personalised adaptation of the diet
• Initiation of dietary intervention at the point of diagnosis/HAART commencement would be beneficial as people living with HIV tend to gain weight on diagnosis, therefore this is a timely and convenient period to commence dietary changes