Lipid profile of antiretroviral therapy-naive HIV-infected patients attending infectious diseases service of University Teaching Hospital of Kinshasa, Democratic Republic of the Congo (DRC)

Introduction: HIV infection leads to metabolic disorders. The objective of this work was to study the lipid profi le of HIV + patients followed at the University Teaching Hospital of Kinshasa (UTHK). Methods: This study analyzes the lipid profi le of HIV + patients, aged at least 18 years, followed at the UTHK from January 1, 2008 to December 31, 2014. The medians of diff erent types of lipids, the frequency of lipid disorders, the general clinical characteristics of patients and factors associated with dyslipidaemia were studied. Haemoglobin (Hb), White Blood Cells (WBC), Leukocyte Formula (LF), Blood Sugar, Urea, Creatinine, Transaminases, Uric Acid, CD4s+ count were analyzed. Results: The lipid balance was performed in 38.8% of patients; 38.1% of them had dyslipidaemia. Total hypercholesterolaemia (28.6%), elevated LDL-C (19%), hypertriglyceridemia (23.8%) and HDL hypocholesterolaemia (42.9%) were observed. The medians of TG (128 mg / dL), HDL-C (51 mg/dL) and LDL-C (78 mg/dL) were high. Risk factors associated with dyslipidaemia were represented by WHO stage 4, tuberculosis (TB) and hyperglycaemia. The highest levels of LDL-C and TG and the lowest HDL-C were seen when CD4s+ were below 200 elements/μL. Conclusion: The HIV/AIDS dyslipidaemia characterized in this study by HDL-C hypocholesterolaemia, hypertriglyceridemia and total and LDL hypercholesterolemia can be considered as an indicator of the progression of HIV infection. Lipid profi le of antiretroviral therapy-naive HIV-infected patients attending infectious diseases service of University Teaching Hospital of Kinshasa, Democratic Republic of the Congo (DRC) https://www.heighpubs.org/hjcv 103 https://doi.org/10.29328/journal.ijcv.1001023 Introduction With the advent of antiretroviral therapy (ART), there has been a reduction in morbidity and mortality of HIV infection which has become a chronic affection. HIV infection leads to a decline in immunity, manifested biologically by a drop in CD4s+ cells. It is also characterized by an increase in viral load [1,2]. In addition to the occurrence of opportunistic infections [OIs (bacterial, parasitic, fungal, and viral)], the HIV is responsible, in the long term, of metabolic disturbances including hyperglycaemia associated with insulin resistance and dyslipidaemia or both. Dyslipidaemia can be caused by the action of HIV per se, OIs, or ART, especially those of the irst generation. In addition to these factors mentioned, other factors are incriminated in the occurrence of dyslipidaemia: weight, lipodystrophy, distribution of fats in the body, age, and diet [3]. The risk and severity of these metabolic alterations are usually increased by individual factors of susceptibility to diabetes mellitus and dyslipidaemia [3]. Restoration of health, changes in body composition and traditional risk factors increase the atherogenic risks responsible of cardiovascular diseases [3]. In general, acute infection induces changes in lipids, lipoproteins and apoproteins serum. These changes occur during the acute phase, convalescence and after complete recovery. HIV infection is a chronic infection in which changes in the lipid pro ile and markers of humoral and cellular immunity have also been observed [4-10]. These lipid abnormalities are related to changes in humoral and cellular immunity and are correlated with immune status and clinical course of HIV infection, which worsens when the immune de iciency widens. These changes are proportional to the drop in CD4s+ cells. Lack of treatment with ARVs is responsible for the development of advanced HIV disease (CD4s + < 200 cells/mm3 or WHO stages 3 or 4). HIV infection involves extensive immune activation and chronic in lammation leading to atherosclerosis. Dyslipidaemia occurring during HIV infection plays a role in the progression of atherosclerotic disease through the in lammation for which it is responsible. Immunosuppression plays a role in the decrease in VLDL clearance via the decrease in the synthesis of hepatic lipoprotein lipases exposing to hypertriglyceridemia. De novo lipogenesis, mediated by certain cytokines, major oxidative stress, and HDL decline explain this correlation between advanced immunosuppression and dyslipidemia. Thus, when the CD4s + count is low, as in advanced HIV disease, immune activation, in lammation, and dyslipidaemia are much greater. This explains why the lipid changes are proportional to the drop in CD4s + cells. [3,6,10,16] The data for HIV-related dyslipidaemia are very variable. Dyslipidaemia in HIV/AIDS is characterized by total hypocholesterolaemia, decrease of HDL-C and LDL-C and increase of triglycerides and VLDL [10-19]. Hypocholesterolaemia is usually early and is associated with an immune dysfunction [14]. Nevertheless, the blood level of total cholesterol can, sometimes, be within normal limits [14] or high [15]. HDL-C and LDL-C levels decrease while immunosuppression increasing in the advanced stage of the disease [16]. In some cases, the LDL-C blood level is rather high [14]. Dyslipidaemia with or without ART during HIV infection have also been described in Africa [20-26]. Hypertriglyceridemia appears late in the course of the disease but was the irst lipid abnormality described in HIV infection. It is due to: The decrease in the clearance of circulating lipoproteins resulting from the decrease in lipoprotein lipase (LPL) level. Stimulation of the synthesis of hepatic lipids through either the synthesis of hepatic fatty acids or a re-etheri ication of fatty acids derived from lipolysis. Ideally, the follow-up of a person infected with HIV should include the blood sugar test and the lipid pro ile at the initial management and at least once a year according to the clinical context of the patient (normal or disturbed initial assessment, personal predispositions to diabetes mellitus or dyslipidaemia etc) [3]. Given the high costs of biochemical examinations, the PNLS (National Control Program) recommends exploring carbohydrate and lipid metabolisms at initial care but does not make it compulsory. In the ART follow-up, the PNLS, also, recommends evaluating these two metabolisms to detect hyperglycaemia and dyslipidaemia in time in the course of the disease under treatment. Little is known on the lipid pro ile of People living with HIV (PLWHIV) in the DRC. As in the management of HIV + patients in health centres and general hospitals, the lipid pro ile is not systematically carried out, this assessment is usually not available. Considering disturbances in the lipid pro ile described in developed countries, the aim of the work is to describe the lipid pro ile to the patients followed at the UTHK, DRC. Methods This study carried out at the UTHK analyzes the data of a retrospective cohort of patients followed in consultation and hospitalization in Infectious Diseases Service from January 1, 2008 to December 31, 2014. It assesses the lipid pro ile of these HIV + patients at inclusion in the cohort before ART. It studies: sociodemographic characteristics: age, sex, marital status, profession, socioeconomic level, ethnicity. WHO clinical stages, history of the disease, clinical characteristics, and OIs. the median values of different types of lipids (Total Cholesterol = TC; High Density Lipoprotein Cholesterol = HDL-C; Low Density Lipoprotein Cholesterol = LDL-C; Triglyceride = TG). Lipid profi le of antiretroviral therapy-naive HIV-infected patients attending infectious diseases service of University Teaching Hospital of Kinshasa, Democratic Republic of the Congo (DRC) https://www.heighpubs.org/hjcv 104 https://doi.org/10.29328/journal.ijcv.1001023 the general characteristics of the population in link to dyslipidaemia. the clinical characteristics of patients. risk factors associated with dyslipidaemia. Besides the lipid pro ile, other haemato-biochemical parameters were evaluated: haemoglobin (Hb). white blood cells (WBC). leukocyte formula (LF). glycaemia. urea and creatinine. transaminases [Aspartate-Amino-Transferase (ASAT) and Alanine-Amino-Transferase (ALAT)]. Uric acid. The reference values used in this study are given in table 1. Statistical analysis Statistical analysis was performed using SPSS (Statistic Package for Social Sciences) software for Windows version 24. The data are presented in the form of the absolute (n) and relative (%) frequencies for the categorical variables, as a mean (± standard deviation) for the quantitative variables with normal distribution and as a median (interquartile range = IQR) for the quantitative variables non-Gaussian distribution. The comparisons between PLWHIVs with a normal lipid pro ile and atherogenic dyslipidaemia were made by the Pearson Chi-square test or Fischer’s exact test as appropriate for the categorical variables, the Student’s t test for the continuous variables. The search for factors associated with atherogenic dyslipidaemia was carried out by the logistic regression test in exploratory univariate analysis. When differences were observed between atherogenic dyslipidaemia and the independent variables, the effect of potential confounders was studied by adjustment in conditional logistic regression in multivariate analysis. The ORs and their 95% CIs were calculated inally to determine the degree of association between atherogenic dyslipidaemia and the independent variables. The signi icance level retained was p < 0.05. Ethical considerations The study concerns a retrospective cohort. Data was collected from medical records. They were entered anonymously and in accordance with ethical rules. The study respected the rules of con identiality, justice and charity of PLWHIV when collecting data anonymously. The service staff took care of the ethical aspects related to this study. Usi ng deidenti ied data, no approval or consent from an ethics or institutional review board was required. Results Out of 270 PLWHIV followed in the UTHK and having been the subjects of this study, 105 (or 38.8%) of them had carried out the lipid assessment. Median values and quartiles of diff erent lipid types The median values of the TC, its fractions and the TGs shown in table 2 are close to the third quartile; 25% of patients respectively have values higher than 92 mg/dl for LDL-C, 132.6 mg/dl for TG and 25% of patients had an HDL-C level lower than 51 mg/dl. The maximum values in our series are much higher than the reference values for TC, LDL-C and TG. For HDL-C, the minimum value is 6.3 mg/dl. Frequency of lipid troubles in the study population The frequency of atherogenic dyslipidaemia in general was 38.1% in PLWHIV followed in our service. Hypercholesterolemia, low HDL-C, high LDL-C and hypertriglyceridaemia were observed in this work as shown in table 3. Table 1: Reference values for haematological and biochemical assessment. Variables Reference Values 1 Hb 12.5 to 15 g/dl for men and 10 to 15 g/dl for women 2 Ht 38 to 52% for men and 32 to 45% for women. 3 WBC 4,000 to less than 10,000 cells/mm3 4 L F: Neutrophils 30% to 60% Lymphocytes 26% to 60% Eosinophils 0% to 12% 5 CD4s+ From 410 to 1590 cells/mm3 6 Urea 10 to 42 mg%. 7 Creatinine 0.5 to 1.2 mg% 8 ASAT 0 to 40 IU/L 9 ALAT 0 to 45 IU/L 10 High TC if value > 200 mg/ dL 11 Hypertriglyceridemia if TG > 150 mg/dL 12 High LDL-C if value > 130 mg/dL 13 Low HDL-C if value < 40 mg/dL for men and < 50 mg/dL for women Table 2: Median values of classes of lipid. Type of lipid, n = 105 Me (IQR) Min-Max TC, mg/dl 144 (125-148) 62,0-260 LDL-c, mg/dl 78,6 (35-92) 19-155,4 HDL-c, mg/dl 51,0 (42,3-67,5) 6,3-190,4 TG, mg/dl 128,0 (99-132,6) 66-286,5 Me = Median; IQR = Interquartile ratio; Min = minimum; Max: Maximum; TC = Total Cholesterol; LDL-C = Low Density Liprotein Cholesterol; HDL-C = High Density Lipoprotein Cholesterol; TG = Triglycerid Table 3: Frequency of lipid troubles in the study. Variable n = 105 % CI 95% Dyslipidaemia in general 40 38,1 28,6-48,5 Hypercholesterolaemia 30 28,6 20,0-38,1 Low HDL-c 45 42,9 33,3-52,4 High LDL-c 20 19,0 11,4-26,7 Hypertriglyceridemia 25 23,8 16,2-32,4 Lipid profi le of antiretroviral therapy-naive HIV-infected patients attending infectious diseases service of University Teaching Hospital of Kinshasa, Democratic Republic of the Congo (DRC) https://www.heighpubs.org/hjcv 105 https://doi.org/10.29328/journal.ijcv.1001023 General characteristics according to dyslipidaemia The table on the general characteristics of PLWHIV according to dyslipidaemia indicates that women had a signi icantly high frequency of dyslipidaemia (p = 0.024), the widowed (p = 0.023), PLHIV with a low level of education (p = 0.005), those of the Revival Churches (p = 0.006), the Luba and Swahili ethnic groups (p < 0.001) (Table 4). Clinical characteristics of patients Table 5 shows that the frequency of dyslipidaemia was signi icantly higher in PLWHIHs with WHO’s stage 4 (p < 0.001), in those with TB (p < 0.001) and anaemia (p = 0.010). Fever and elevated mean RR were signi icantly more encountered in PLHIV with dyslipidaemia. The frequency of vomiting is low in this group of PLWHIVs (p = 0.016). Biological examinations In P LHIV with dyslipidaemia, the average values of Hb were signi icantly lower while the average values of blood sugar (p = 0,001), urea and WBC were higher (p < 0.05) (Table 6). Table 4: General characteristics according to dyslipidaemia. Variable All = 105 Normal n = 65 Dyslipidaemia n = 40 p Age (year) ± SD 44,5 ± 11,5 44,9 ± 10,8 43,9 ± 11,5 0,651 Sex 0,024 Male 40(38,1) 30(46,2) 10(25,0) Female 65(61,9) 35(53,8) 30(75,0) Civil Status 0,023 Maried 45(47,4) 30(50,0) 15(42,9) Divorced 5(5,3) 5(8,3) 0(0,0) Single 30(31,6) 20(33,3) 10(28,6) Widower 15(15,8) 5(8,3) 10(28,6) Profession 0,443 Unemployed 40(47,1) 25(45,5) 15(50,0) State worker 15(17,6) 10(18,2) 5(16,7) Junior Company Agent 5(5,9) 5(9,1) 0(0,0) Liberal Profession 25(29,4) 15(27,3) 10(33,3) Level of studies 0,005 Primary 5(8,3) 0(0,0) 5(25,0) Secondary 35(58,3) 25(62,5) 10(50,0) University level 20(33,3) 15(37,5) 5(25,0) Religion 0,006 Catholic 30(42,9) 20(57,1) 10(28,6) Revival Church 35(50,0) 15(42,9) 20(57,1) Other 5(7,1) 0(0,0) 5(14,3) Socioeconomic level 0,056 Intermediary 35(87,5) 15(75,0) 20(100,0) Low 5(12,5) 5(25,0) 0(0,0) Ethnic group < 0,001 Kongo 40(50,0) 30(60,0) 10(33,3) Ngala 15(18,8) 15(30,0) 0(0,0) Luba 15(18,8) 5(10,0) 10(33,3) Swahili 10(12,5) 0(0,0) 10(33,3) SD = Standard Deviation Table 5: Patient’s clinical characteristics. Variables All n = 105 Normal n = 65 Dyslipidaemia n = 40 p WHO Stages < 0,001 Stage 1 15(14,3) 10(15,4) 5(12,5) Stage 2 5(4,8) 5(7,7) 0(0,0) Stage 3 30(28,6) 30(46,2) 0(0,0) Stage 4 55(52,4) 20(30,8) 35(87,5) Antecedents TB 30(28,6) 5(7,7) 25(62,5) < 0,001 Meningeal cryptococcosis 10(9,5) 5(7,7) 5(12,5) 0,313 Oral candidiasis 15(14,3) 10(15,4) 5(12,5) 0,458 Co-infection VHB-VHC 10(11,1) 5(9,1) 5(14,3) 0,332 HTA 15(14,3) 10(15,4) 5(12,5) 0,458 Smoking 10(9,5) 5(7,7) 5(12,5) 0,313 Alcohol intake 20(19,0) 15(23,1) 5(12,5) 0,139 Clinic Fever 80(76,2) 45(69,2) 35(87,5) 0,026 Weight loss 50(47,6) 30(46,2) 20(50,0) 0,428 Diarrhoea 95(90,5) 60(92,3) 35(87,5) 0,313 Cough 90(85,7) 55(84,6) 35(87,5) 0,458 Vomiting 90(85,7) 60(92,3) 30(75,0) 0,016 Headache 10(9,5) 5(7,7) 5(12,5) 313 Pallor 30(28,6) 25(38,5) 5(12,5) 0,003 Lymphadenopathy 15(14,3) 10(15,4) 5(12,5) 0,458 Lateralization signs 10(9,5) 5(7,7) 5(12,5) 0,313 SBP 124,2 ± 17,1 123,7 ± 12,6 125,0 ± 22,8 0,706 DBP 79,3 ± 14,5 79,4 ± 11,4 79,1 ± 18,6 0,930 Pulse 87,9 ± 12,2 89,4 ± 13,8 85,6 ± 8,9 0,127 RR 21,5 ± 4,9 20,8 ± 2,6 22,9 ± 7,1 0,041 BMI 24,8 ± 7,8 25,3 ± 8,6 22,8 ± 2,1 0,368 Comorbidities TB 30(28,6) 5(7,7) 25(62,5) < 0,001 Oral candiasis 15(14,3) 10(15,4) 5(12,5) 0,458 Anaemia 25(23,8) 10(15,4) 15(37,5) 0,010 Meningeal cryptococcosis 10(9,5) 5(7,7) 5(12,5) 0,313 WHO = World Health Organization; TB = Tuberculosis; VHB = Viral Hepatitis B; VBC = Viral Hepatitis C; HTA = Hypertension; SBP = Systolic Blood Pressure; RR = Respiratory Rate. Table 6: Biological examinations. Variable n All Normal Dyslipidaemia p Hb (g/l) 90 9,4 ± 2,9 10,5 ± 2,9 8,8 ± 2,9 0,008 Ht (%) 70 30,3 ± 7,7 31,7 ± 6,4 27,8 ± 9,3 0,042 WBC (Cell/mm3) 90 5847,8 ± 186,1 5254,1 ± 176,6 7035,0 ± 144,7 0,001 Neutrophile (%) 90 57,9 ± 12,9 57,5 ± 12,8 59,0 ± 13,2 0,602 Lymphocyte (%) 90 38,1 ± 12,1 37,7 ± 11,3 39,0 ± 13,6 0,636 Glycaemia (mg/dl) 60 96,8 ± 25,9 88,9 ± 16,9 120,3 ± 33,6 < 0,001 Urea (mg/dl) 95 31,1 ± 4,9 21,4 ± 6,5 52,0 ± 3,8 < 0,001 Creatinine (mg/dl) 95 1,4 ± 0,4 1,4 ± 0,6 1,2 ± 0,5 0,562 ASAT (UI/l) 95 31,1 ± 13,8 32,0 ± 14,8 28,9 ± 12,6 0,508 ALAT (UI/l) 95 30,4 ± 12,8 26,6 ± 9,3 38,7 ± 14,3 0,053 Uric Acid (mg/dl) 105 1,7 ± 0,4 1,9 ± 0,2 1,4 ± 0,5 0,460 CD4+ cell/mm3 105 229,5 ± 21,7 220,6 ± 21,5 243,9 ± 22,3 0,597 Hb = Haemoglobin; Ht = Haematocrit; WBC = White Blood Cell; g/l = gram per litter; Cell/mm3 = Cell per cubic milliliter; mg/dl = milligram per deciliter; ASAT = Aspartate-Amino-Transferase; ALAT = Alanine-Amino-Transferase; CD4+ = Cluster of diff erentiation four. Lipid profi le of antiretroviral therapy-naive HIV-infected patients attending infectious diseases service of University Teaching Hospital of Kinshasa, Democratic Republic of the Congo (DRC) https://www.heighpubs.org/hjcv 106 https://doi.org/10.29328/journal.ijcv.1001023 Risk factors associated with atherogenic dyslipidaemia in the study population. The risk factors associated with atherogenic dyslipidaemia in the univariate analysis were female, stage 4 of the WHO, presence of TB, anaemia, and hyperglycaemia. After adjustment in multivariate analysis, female with risk multiplied by 3, WHO stage 4 (risk multiplied by 2), TB (risk multiplied by 9) and hyperglycaemia (risk multiplied by 8) were the factors patients associated with atherogenic dyslipidaemia (Table 7). The LDL-C and TG levels were signi icantly higher and the HDL-C level low when the CD4 count was less than 200 elements per mm3 (Table 8). Discussion This study analyzes the lipid pro ile of HIV + patients who have been followed up at UTHK. It highlights the lipid abnormalities observed in patients who have performed the lipid balance. Lipid assessment was only performed in 38.8% of patients. This score is low. The low number of patients who have performed the lipid assessment is because the examinations are expensive and are not accessible to all PLWHIV. Healthcare providers do not systematically ask for the lipid pro ile in the care of PLWHIV either. The PNLS (AIDS and STI Control Program) recommends the realization of the lipid pro ile when including patients in the care, but it does not have the possibility of subsidizing the biological assessment. Hence only those who have the inancial resources do the exams. Median values and quartiles of diff erent types of lipid The median values of CT, LDL-C, HDL-C and TG indicate that there are lipid abnormalities. The median value of the CT is high and is above 50% of the value of the upper limit of the reference value. The same is true of the medians of LDL-C and TG. The minimum value of HDL-C is extremely low and is a good indication for atherogenic dyslipidaemia. Frequency of lipid disorders in the study population Table 9 shows the results of some studies on dyslipidaemia in HIV-infected patients. These results are compared to ours. Regarding to the atherogenic risk, the 2 most important parameters in dyslipidaemia are HDL-C and TG compared to changes in TC and LDL-C [10]. Acute infection [4,5] and HIV infection are the basis of lipid abnormalities [6,8,13]. General characteristics according to dyslipidaemia In this study, dyslipidaemia is predominant among women, members of revival churches, Luba and Swahili ethnicities, and low educational levels. The differences observed are statistically signi icant. However, we do not have a speci ic explanation based on scienti ic evidence to provide. Subject to the small sample size, it is dif icult to draw a conclusion. A study with a larger sample considering the food composition of different subgroups, genetics, environment, and many other factors is needed to decide. The advanced stage (stage 4) of the disease is a factor in luencing the lipid pro ile. The occurrence of OIs may also explain the dyslipidaemia in HIV patients. TB is an OI disease with chronic in lammation and the supply of in lammatory cytokines may explain dyslipidaemia. Anaemia is common in HIV infection. It is a consequence of chronic in lammation with the possibility of iron sequestration in macrophages. In this study, PLHIV with dyslipidaemia have low mean Hb and higher level of blood sugar values. Low Hb is linked to chronic in lammation as mentioned above and probably to the frequent malnutrition in PLHIV with advanced HIV infection. During HIV infection, cardiometabolic complications may be observed. The elevated blood glucose values observed in this series in some patients may be placed in the context of the metabolic complications of HIV disease. On the other hand, the high mean values of urea can be linked to comorbidity (dehydration? Chronic kidney disease?). This study shows, in univariate analysis, that stage 4, TB and hyperglycaemia are risk factors associated with dyslipidaemia. Stage 4 is a pejorative factor leading to dyslipidaemia. The same is true of TB which is a chronic in lammatory condition and hyperglycaemia. In this series, after adjustment in multivariate analysis, the risk is multiplied by 3 in women, by 2 for stage 4 and by 9 for TB. High blood sugar is an 8-fold risk factor. Advanced immunosuppression increases the risk of developing hypertriglyceridemia and LDL hypercholesterolemia, especially when the CD4 count is below 200 elements per mm3. Table 7: Factors associated with atherogenic dyslipidaemia in the study. Variable Univariate Analysis Multivariate Analysis p OR (CI95%) p ORa (CI95%) Sex Male 1 1 Female 0,033 2,57(1,08-6,11) 0,017 3,10(1,22-7,86) WHO Stage 4 No 1 1 Yes 0,002 2,27(1,34-3,85) 0,007 2,11(1,23-3,62) TB No 1 1 Yes 0,000 6,00(2,56-9,60) 0,000 8,67(5,72-10,89) Anaemia No 1 1 Yes 0,012 3,30(1,30-8,36) 0,749 1,22(0,36-4,18) Hyperglycaemia No 1 1 Yes 0,000 6,00(3,87-12,21) 0,009 8,00(3,69-17,67) OR = Odds Ratio; ORa = Odds Ratio a; CI = Confi dence Interval Table 8: Lipid profi le according to CD4+ count. Lipid profi le < 200 n = 65 200-499 n = 30 ≥ 500 n = 10 p TC, mg/dL 162,6 ± 50,4 153,0 ± 14,3 146,0 ± 28,2 0,097 LDL-c, mg/dL 86,1 ± 15,2 74,2 ± 23,3 50,6 ± 16,2 0,067 HDL-c, mg/dL 44,0 ± 24,2 54,6 ± 24,3 66,6 ± 25,9 0,041 Triglycéride, mg/dL 158,9 ± 25,5 120,9 ± 27,2 94,6 ± 25,3 0,001 TC = Total Cholesterol; LDL-C = Low Density Lipoprotein Cholesterol; HDL-C = High Density Lipoprotein Cholesterol; Lipid profi le of antiretroviral therapy-naive HIV-infected patients attending infectious diseases service of University Teaching Hospital of Kinshasa, Democratic Republic of the Congo (DRC) https://www.heighpubs.org/hjcv 107 https://doi.org/10.29328/journal.ijcv.1001023 Ta bl e 9: C om pa ra bl e lit er at ur e da ta o f s om e st ud ie s on d ys lip id ae m ia in H IV p at ie nt s.


Introduction
With the advent of antiretroviral therapy (ART), there has been a reduction in morbidity and mortality of HIV infection which has become a chronic affection. HIV infection leads to a decline in immunity, manifested biologically by a drop in CD4s + cells. It is also characterized by an increase in viral load [1,2]. In addition to the occurrence of opportunistic infections [OIs (bacterial, parasitic, fungal, and viral)], the HIV is responsible, in the long term, of metabolic disturbances including hyperglycaemia associated with insulin resistance and dyslipidaemia or both. Dyslipidaemia can be caused by the action of HIV per se, OIs, or ART, especially those of the irst generation. In addition to these factors mentioned, other factors are incriminated in the occurrence of dyslipidaemia: weight, lipodystrophy, distribution of fats in the body, age, and diet [3]. The risk and severity of these metabolic alterations are usually increased by individual factors of susceptibility to diabetes mellitus and dyslipidaemia [3]. Restoration of health, changes in body composition and traditional risk factors increase the atherogenic risks responsible of cardiovascular diseases [3].
In general, acute infection induces changes in lipids, lipoproteins and apoproteins serum. These changes occur during the acute phase, convalescence and after complete recovery. HIV infection is a chronic infection in which changes in the lipid pro ile and markers of humoral and cellular immunity have also been observed [4][5][6][7][8][9][10]. These lipid abnormalities are related to changes in humoral and cellular immunity and are correlated with immune status and clinical course of HIV infection, which worsens when the immune de iciency widens. These changes are proportional to the drop in CD4s + cells. Lack of treatment with ARVs is responsible for the development of advanced HIV disease (CD4s + < 200 cells/mm 3 or WHO stages 3 or 4). HIV infection involves extensive immune activation and chronic in lammation leading to atherosclerosis. Dyslipidaemia occurring during HIV infection plays a role in the progression of atherosclerotic disease through the in lammation for which it is responsible. Immunosuppression plays a role in the decrease in VLDL clearance via the decrease in the synthesis of hepatic lipoprotein lipases exposing to hypertriglyceridemia. De novo lipogenesis, mediated by certain cytokines, major oxidative stress, and HDL decline explain this correlation between advanced immunosuppression and dyslipidemia. Thus, when the CD4s + count is low, as in advanced HIV disease, immune activation, in lammation, and dyslipidaemia are much greater. This explains why the lipid changes are proportional to the drop in CD4s + cells. [3,6,10,16] The data for HIV-related dyslipidaemia are very variable. Dyslipidaemia in HIV/AIDS is characterized by total hypocholesterolaemia, decrease of HDL-C and LDL-C and increase of triglycerides and VLDL [10][11][12][13][14][15][16][17][18][19]. Hypocholesterolaemia is usually early and is associated with an immune dysfunction [14]. Nevertheless, the blood level of total cholesterol can, sometimes, be within normal limits [14] or high [15]. HDL-C and LDL-C levels decrease while immunosuppression increasing in the advanced stage of the disease [16]. In some cases, the LDL-C blood level is rather high [14].
Hypertriglyceridemia appears late in the course of the disease but was the irst lipid abnormality described in HIV infection. It is due to: -The decrease in the clearance of circulating lipoproteins resulting from the decrease in lipoprotein lipase (LPL) level.
-Stimulation of the synthesis of hepatic lipids through either the synthesis of hepatic fatty acids or a re-etheri ication of fatty acids derived from lipolysis.
Ideally, the follow-up of a person infected with HIV should include the blood sugar test and the lipid pro ile at the initial management and at least once a year according to the clinical context of the patient (normal or disturbed initial assessment, personal predispositions to diabetes mellitus or dyslipidaemia etc) [3].
Given the high costs of biochemical examinations, the PNLS (National Control Program) recommends exploring carbohydrate and lipid metabolisms at initial care but does not make it compulsory. In the ART follow-up, the PNLS, also, recommends evaluating these two metabolisms to detect hyperglycaemia and dyslipidaemia in time in the course of the disease under treatment. Little is known on the lipid pro ile of People living with HIV (PLWHIV) in the DRC. As in the management of HIV + patients in health centres and general hospitals, the lipid pro ile is not systematically carried out, this assessment is usually not available.
Considering disturbances in the lipid pro ile described in developed countries, the aim of the work is to describe the lipid pro ile to the patients followed at the UTHK, DRC.

Methods
This study carried out at the UTHK analyzes the data of a retrospective cohort of patients followed in consultation and hospitalization in Infectious Diseases Service from January 1, 2008 to December 31, 2014. It assesses the lipid pro ile of these HIV + patients at inclusion in the cohort before ART. It studies: -sociodemographic characteristics: age, sex, marital status, profession, socioeconomic level, ethnicity.
-WHO clinical stages, history of the disease, clinical characteristics, and OIs. -the general characteristics of the population in link to dyslipidaemia.
-the clinical characteristics of patients.
-risk factors associated with dyslipidaemia.
The reference values used in this study are given in table 1.

Statistical analysis
Statistical analysis was performed using SPSS (Statistic Package for Social Sciences) software for Windows version 24.
The data are presented in the form of the absolute (n) and relative (%) frequencies for the categorical variables, as a mean (± standard deviation) for the quantitative variables with normal distribution and as a median (interquartile range = IQR) for the quantitative variables non-Gaussian distribution. The comparisons between PLWHIVs with a normal lipid pro ile and atherogenic dyslipidaemia were made by the Pearson Chi-square test or Fischer's exact test as appropriate for the categorical variables, the Student's t test for the continuous variables. The search for factors associated with atherogenic dyslipidaemia was carried out by the logistic regression test in exploratory univariate analysis.
When differences were observed between atherogenic dyslipidaemia and the independent variables, the effect of potential confounders was studied by adjustment in conditional logistic regression in multivariate analysis. The ORs and their 95% CIs were calculated inally to determine the degree of association between atherogenic dyslipidaemia and the independent variables. The signi icance level retained was p < 0.05.

Ethical considerations
The study concerns a retrospective cohort. Data was collected from medical records. They were entered anonymously and in accordance with ethical rules. The study respected the rules of con identiality, justice and charity of PLWHIV when collecting data anonymously. The service staff took care of the ethical aspects related to this study. Usi ng deidenti ied data, no approval or consent from an ethics or institutional review board was required.

Results
Out of 270 PLWHIV followed in the UTHK and having been the subjects of this study, 105 (or 38.8%) of them had carried out the lipid assessment.

Median values and quartiles of diff erent lipid types
The median values of the TC, its fractions and the TGs shown in table 2 are close to the third quartile; 25% of patients respectively have values higher than 92 mg/dl for LDL-C, 132.6 mg/dl for TG and 25% of patients had an HDL-C level lower than 51 mg/dl. The maximum values in our series are much higher than the reference values for TC, LDL-C and TG. For HDL-C, the minimum value is 6.3 mg/dl.

Frequency of lipid troubles in the study population
The frequency of atherogenic dyslipidaemia in general was 38.1% in PLWHIV followed in our service. Hypercholesterolemia, low HDL-C, high LDL-C and hypertriglyceridaemia were observed in this work as shown in table 3.

General characteristics according to dyslipidaemia
The table on the general characteristics of PLWHIV according to dyslipidaemia indicates that women had a signi icantly high frequency of dyslipidaemia (p = 0.024), the widowed (p = 0.023), PLHIV with a low level of education (p = 0.005), those of the Revival Churches (p = 0.006), the Luba and Swahili ethnic groups (p < 0.001) ( Table 4). Table 5 shows that the frequency of dyslipidaemia was signi icantly higher in PLWHIHs with WHO's stage 4 (p < 0.001), in those with TB (p < 0.001) and anaemia (p = 0.010). Fever and elevated mean RR were signi icantly more encountered in PLHIV with dyslipidaemia. The frequency of vomiting is low in this group of PLWHIVs (p = 0.016).

Biological examinations
In P LHIV with dyslipidaemia, the average values of Hb were signi icantly lower while the average values of blood sugar (p = 0,001), urea and WBC were higher (p < 0.05) ( Table 6).   Risk factors associated with atherogenic dyslipidaemia in the study population.
The risk factors associated with atherogenic dyslipidaemia in the univariate analysis were female, stage 4 of the WHO, presence of TB, anaemia, and hyperglycaemia.
After adjustment in multivariate analysis, female with risk multiplied by 3, WHO stage 4 (risk multiplied by 2), TB (risk multiplied by 9) and hyperglycaemia (risk multiplied by 8) were the factors patients associated with atherogenic dyslipidaemia ( Table 7).
The LDL-C and TG levels were signi icantly higher and the HDL-C level low when the CD4 count was less than 200 elements per mm 3 (Table 8).

Discussion
This study analyzes the lipid pro ile of HIV + patients who have been followed up at UTHK. It highlights the lipid abnormalities observed in patients who have performed the lipid balance. Lipid assessment was only performed in 38.8% of patients. This score is low. The low number of patients who have performed the lipid assessment is because the examinations are expensive and are not accessible to all PLWHIV. Healthcare providers do not systematically ask for the lipid pro ile in the care of PLWHIV either. The PNLS (AIDS and STI Control Program) recommends the realization of the lipid pro ile when including patients in the care, but it does not have the possibility of subsidizing the biological assessment. Hence only those who have the inancial resources do the exams.

Median values and quartiles of diff erent types of lipid
The median values of CT, LDL-C, HDL-C and TG indicate that there are lipid abnormalities. The median value of the CT is high and is above 50% of the value of the upper limit of the reference value. The same is true of the medians of LDL-C and TG. The minimum value of HDL-C is extremely low and is a good indication for atherogenic dyslipidaemia. Table 9 shows the results of some studies on dyslipidaemia in HIV-infected patients. These results are compared to ours.

Frequency of lipid disorders in the study population
Regarding to the atherogenic risk, the 2 most important parameters in dyslipidaemia are HDL-C and TG compared to changes in TC and LDL-C [10]. Acute infection [4,5] and HIV infection are the basis of lipid abnormalities [6,8,13].

General characteristics according to dyslipidaemia
In this study, dyslipidaemia is predominant among women, members of revival churches, Luba and Swahili ethnicities, and low educational levels. The differences observed are statistically signi icant. However, we do not have a speci ic explanation based on scienti ic evidence to provide. Subject to the small sample size, it is dif icult to draw a conclusion. A study with a larger sample considering the food composition of different subgroups, genetics, environment, and many other factors is needed to decide.
The advanced stage (stage 4) of the disease is a factor in luencing the lipid pro ile. The occurrence of OIs may also explain the dyslipidaemia in HIV patients. TB is an OI disease with chronic in lammation and the supply of in lammatory cytokines may explain dyslipidaemia. Anaemia is common in HIV infection. It is a consequence of chronic in lammation with the possibility of iron sequestration in macrophages. In this study, PLHIV with dyslipidaemia have low mean Hb and higher level of blood sugar values. Low Hb is linked to chronic in lammation as mentioned above and probably to the frequent malnutrition in PLHIV with advanced HIV infection. During HIV infection, cardiometabolic complications may be observed. The elevated blood glucose values observed in this series in some patients may be placed in the context of the metabolic complications of HIV disease. On the other hand, the high mean values of urea can be linked to comorbidity (dehydration? Chronic kidney disease?). This study shows, in univariate analysis, that stage 4, TB and hyperglycaemia are risk factors associated with dyslipidaemia. Stage 4 is a pejorative factor leading to dyslipidaemia. The same is true of TB which is a chronic in lammatory condition and hyperglycaemia. In this series, after adjustment in multivariate analysis, the risk is multiplied by 3 in women, by 2 for stage 4 and by 9 for TB. High blood sugar is an 8-fold risk factor.

Advanced
immunosuppression increases the risk of developing hypertriglyceridemia and LDL hypercholesterolemia, especially when the CD4 count is below 200 elements per mm 3 .

Conclusion
Lipid abnormalities were observed in patients who have performed the lipid balance in this study. Atherogenic dyslipidaemia was demonstrated. It was associated with certain independent factors (female gender, WHO stage 4, TB and hyperglycemia). Dyslipidaemia gives an indication of the progression of the disease in PLHIV.