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Low Rates of Cholesterol Screening Despite Cardiovascular Risk In Protease-Inhibitor
Treated HIV Patients in Botswana
Mosepele Mosepele1,2,3,4, Lucky Mokgatlhe5,Frank P Hudson6, Virginia Letsatsi,4 Robert Gross, 7,8
Department of Medicine, University of Botswana,1Botswana-Harvard AIDS Partnership,2 Harvard T. H Chan School of Public Health,3 Princess Marina Hospital Infectious Disease Care
Clinic, Botswana,4 Department of Biostatistics, University of Botswana,5 Division of Infectious Diseases, University of North Carolina, USA,6 Division of Infectious Disease, University of
Pennsaylvania Perelman School of Medicine, USA,7 Botswana-UPenn Partnership, Botswana, 8
Introduction
• Treatment of Human Immunodeficiency
Virus (HIV) with Protease Inhibitors (PIs)
is associated with increase in serum
cholesterol levels
• PI induced hypercholesterolemia is
strongest among those on first
generation ritonavir boosted PIs
[commonly used in sub-Saharan Africa]
• In other settings, use of general
population cholesterol guidelines is
recommended among HIV patients to
reduce cardiovascular (CVD) risk
• The American Heart
Association/American College of
Cardiology issued a new cholesterol
recommendation (ASCVD) in 2013,
which replaced the Framingham risk
score (FRS)
• Our objective was to assess
cholesterol screening and ascertain
proportion of PI treated HIV-infected
patients who would be considered for
statin therapy in a clinical HIV-cohort
in Botswana based on ASCVD versus
FRS
50-59
(11.5)
Contact:
Mosepele Mosepele MD,41MSc
Department of Medicine, Faculty of Medicine
University of Botswana
Phone: +267 355 5589
Email: [email protected]
[email protected]
Abstract: WEPDB0106
Hypotheses
Methods
• Cholesterol screening rate are low in
usual clinical practice among PI-treated
HIV-infected patients
• Study setting was a large referral urban HIV
clinic with over 8,000 HIV-infected patients
• Aimed to screen 400-500 patients over
age 21-years on PI-containing ART on
consecutive days over 3-6 months during
routine clinic visit
• Data on traditional CVD risk factors was
obtained from medical records and brief
participant interview
• Cholesterol screening assessed each
year between 2008 and 2011 (as per the
2008 national HIV guideline
recommendation)
• Participants recommended non-fasting lipid
profile testing if they did not have a lipid
profile within 12 months at time of enrollment
• Recommendation for evaluation for statin
use based on ASCVD risk score as of 2013
and ATP III risk score as of 12/31/2008
• Risk score calculated using data from a 12
month window
• Exclusion criteria: NNRTI-based ART
• Rates of hypercholesterolemia
(>5.0mmol/L), statin use, proportion
recommended statin calculated, and
agreement between ASCVD & FRS
assessed using Kappa statistic
• More patients will be recommended for
statin therapy evaluation based on
ASCVD than FRS
Low Rates of Cholesterol Screening Despite Cardiovascular Risk In Protease-Inhibitor
Treated HIV Patients in Botswana
Mosepele Mosepele1,2,3,4, Lucky Mokgatlhe5,Frank P Hudson6, Virginia Letsatsi,4 Robert Gross, 7,8
Department of Medicine, University of Botswana,1Botswana-Harvard AIDS Partnership,2 Harvard T. H Chan School of Public Health,3 Princess Marina Hospital Infectious Disease Care
Clinic, Botswana,4 Department of Biostatistics, University of Botswana,5 Division of Infectious Diseases, University of North Carolina, USA,6 Division of Infectious Disease, University of
Pennsaylvania Perelman School of Medicine, USA,7 Botswana-UPenn Partnership, Botswana, 8
50-59
(11.5)
Contact:
Mosepele Mosepele MD,41MSc
Department of Medicine, Faculty of Medicine
University of Botswana
Phone: +267 355 5589
Email: [email protected]
[email protected]
Abstract: WEPDB0106
Results
All
DEMOGRAPHICS
N
375
Female - N (%)
239 (63.7)
Age Category - N (%)
21-39
167 (46.6)
40-49
135 (37.7)
50-59
41 (11.5)
>60
15 (4.2)
CVD RISK FACTORS – N (%)
Cigarette smoking
85 (22.7)
HTN
34 (9.1)
HTN medications
31 (91)
DM II
7 (1.9)
DM II medications
6 (86)
Dyslipidemia
9 (2.4)
Statin use
6 (67)
Prior CVD
2 (0.005)
HIV PARAMETERS- N (%)
HIV duration
8.9 (2.8)
ART duration
7.2 (2.2)
Baseline CD4
118.5 (86.3)
CD4 nadir
104.9 (75.4)
Current CD4
513.9 (286.1)
Viral load undetectable
344 (91.7)
CVD RISK PARAMETERS – mean (SD)
Systolic blood pressure (mmHg)
117.3 (18.3)
Diastolic blood pressure (mmHg)
72.9 (12.6)
Total cholesterol
4.6 (1.1)
LDL-cholesterol
2.8 (0.9)
HDL-cholesterol
1.3 (0.4)
Triglycerides
1.7 (1.2)
• Hypercholesterolemia was detected among 94 (31%)
of participants, in contrast to baseline
hypercholesterolemia rate of 2.4% in the medical
records
• There was moderate agreement in recommendation
for statin therapy: 14.3% by ASCVD versus 9.4% by
FRS – [Kappa statistic 0.68, 95% CI 0.54-0.82,
p<0.001]
Figure 1. Proportion of patients who were screened for
dyslipidemia using usual clinical practice before study
enrollment (2008 to 2011) and during study enrollment
(2012).
Conclusion
• Provider initiated cholesterol screening during routine
clinical care is low in this setting
• When recommended to go for cholesterol screening
in study setting using standard of care procedures, a
majority of patients underwent screening
• Hypercholesterolemia was higher that the
documented rate in medical records (2.4% versus
31%)
• In this setting, ASCVD would result in more patients
recommended statin therapy than FRS, a finding that
has been observed in other clinical cohorts
• Interventions are needed to increase cholesterol
screening and evaluate strategies for statin
prescription for primary CVD risk reduction among
HIV-infected patients
Table 1: Patient characteristics. Demographic and
clinical characteristics
Acknowledgements
Work inspired by Virginia A Triant, MD, MGH/HMS work on CVD epidemiology