Lipid metabolism and cardiovascular risk in HIV infection: new perspectives and the role of nevirapine.

Effective antiretroviral regimens allow patients to successfully manage their HIV infection for decades. Both HIV infection and treatment elevate the incidence and progression of cardiovascular disease, as evidenced by higher rates of myocardial infarction. Traditional cardiovascular disease risk factors, including elevated serum lipids, lipoprotein and triglyceride levels, hypertension, and smoking, may play a role. In addition, factors directly related to HIV infection (chronic inflammation and persistent immune activation due to viral replication) further elevate risk, while some antiretrovirals adversely affect serum lipids and promote inflammation. Recent epidemiological studies report that HIV-infection rates in patients aged 50 years or greater are rising. Since HIV patients experience decades of elevated cardiovascular disease risk, and many patients are infected later in life, older patients are generally at even greater cardiovascular disease risk. Treatment guidelines recommend antiretroviral regimen initiation soon after initial diagnosis, with continuous adherence to minimize long-term consequences of HIV infection. Also, appropriate selection when initiating or switching antiretroviral regimens can play a major role in managing cardiovascular disease risk. Antiretroviral drugs with favorable lipid profiles may help. Close adherence to the NCEP guidelines for managing hyperlipidemias and other cardiovascular risk factors further reduces cardiovascular disease risk. Recent awareness of other patient factors, such as the impact of vitamin D deficiencies on cardiovascular disease risk, especially in the HIV-infected population, raises important questions with regard to the potential benefits of vitamin D repletion via supplementation. Fortunately, these and other important cardiovascular disease risk management questions designed to improve patient care are currently being addressed in large, well-controlled clinical trials.