Background:  ART use, particularly with protease inhibitors (PI) and stavudine (4dT), has been linked to dyslipidemia and increased risk of cardiovascular disease in HIV-infected patients in industrialized countries. Its effects on lipid metabolism in patients in Sub-Saharan Africa, where ART programs are rapidly expanding, remain largely unknown.

Methods:  From May 2003 to December 2004, 1029 ART-naïve patients with symptomatic HIV disease or CD4 cell counts ≤250 cells/mm³ initiated HAART in the Home-based AIDS Care (HBAC) program in Tororo, a rural area of Uganda. Non-fasting repository sera from a subset of 596 patients were analyzed for total cholesterol (TC), direct low-density lipopoprotein cholesterol (LDL), direct high-density lipoprotein cholesterol (HDL), and triglyceride (TG) levels prior to HAART and after 12 and 24 months of therapy.

Results:  Patients (59% women, median age 39 years, median CD4 cell count 118 cells/mm³, median body mass index 19.4 kg/m²) received 4dT plus lamivudine (3TC) with either nevirapine (NVP) (574 patients, 96%) or efavirenz (EFV) (22 patients, 4%). During 24 months of treatment, 12 (2%) patients switched to second-line HAART, which included lopinavir/ritonavir (LPV/r); their observations after the switch were excluded. Single-drug substitutions included zidovudine (AZT) for 4dT (136 patients, 23%), and EFV for NVP (36 patients, 6%). Baseline median serum lipid concentrations (mg/dL) were 117 for TC, 49 for LDL, 26 for HDL, and 119 for TG, and were comparable for men and women. Among 480 patients with both baseline and 24-month data, TC increased by a median of 24%, LDL by 54%, HDL by 62%, whereas TC:HDL ratio decreased by 24% and TG decreased by 15% (all changes, t-test p <0.01). At baseline and 24 months, respectively, TC was ≥200 mg/dL for 3% and 11% of patients, LDL was >130 mg/dL for 1% and 6%, HDL was <40 mg/dL for 89% and 42%, and TG were ≥150 mg/dL for 29% and 20%.

Conclusions:  Among persons with advanced HIV disease in rural Uganda, elevated TC, LDL, and TG were infrequent before and after 2 years of non-nucleoside reverse transcriptase inhibitor-based HAART. HDL levels increased substantially. The effect of lipid profiles on cardiovascular disease risk in this population is largely unknown; however, the changes we observed after 24 months of HAART appear unlikely to increase the risk of cardiovascular disease.