World Journal of AIDS, 2013, 3, 293-297
Published Online December 2013 (
Open Access WJA
Metabolic Syndrome in People with HIV/AIDS
Ana Paula Werberich1, Juliana Ceren1, Jayder Lucas Hotts Romancini2,
Giuliano Gomes de Assis Pimentel1, Miguel Spack Junior1, Áurea Regina Telles Pupulin3
1Department of Medicine, Universidade Estadual de Maringá, Maringá, Brazil; 2Department of Physical Education, Universidade
Estadual de Maringá, Maringá, Brazil; 3Department of Basic Health Sciences, Universidade Estadual de Maringá, Maringá, Brazil.
Received July 16th, 2013; revised August 12th, 2013; accepted August 19th, 2013
Copyright © 2013 Ana Paula Werberich et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Highly Active Antiretroviral Therapy (HAART) has changed the clinical picture of HIV infection by
reducing morbidity and mortality rates in the population. However, alterations in lipid metabolism leading to hyper-
triglyceridemia, hypercholesterolemia, insulin resistance, hyperglycemia and redistribution of body fat, which are risk
factors for cardiovascular diseases, have emerged. Metabolic Syndrome (MS) is a complex disorder represented by a set
of cardiovascular risk factors commonly associated with central adiposity and insulin resistance. Aim: Current paper
evaluates the prevalence of MS in patients with HIV/AIDS using HAART from a reference Center in southern Brazil.
Methods: Samples comprised patients who had the infection for at least five years and were undergoing antiretroviral
therapy. Metabolic syndrome was identified according to the National Cholesterol Education Program Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATPIII). A physical examination
was performed by evaluating percentage of body fat by bio-impedance and measuring blood pressure, determination of
Body Mass Index and Waist-Hip Ratio, glycaemia, total cholesterol, HDL cholesterol, LDL cholesterol and triglyc-
erides. Results: 184 patients were evaluated. MS prevalence was 30% (55 patients), with 30 (16.3%) males and 25
(13.7%) females. Conclusions: Brazil was among the first country profoundly impacted by the HIV/AIDS epidemic but
today, Brazil has less than 1% adult HIV prevalence, implemented treatment and prevention programs early in the epi-
demic. W her eas th er e is cu rren tly a sig nif ican t in crea se in th e survival of HIV patients by HAART, the patients reveal a
higher prevalence of Metabolic Syndrome in this specific population requiring political strategy of care to this popula-
Keywords: HIV/AIDS; Metabolic Syndrome; Metabolic Abnormalities; Brazil
1. Introduction
Brazil has currently 656,701 registered AIDS cases, with
38,776 new registered cases of HIV infection in 2012.
The above data rank second for reported cases for AIDS
in the Americas [1].
The Brazilian gov ernment’s policy to respon d to AIDS
with the universal, free su pply of antiretrovir al drugs and
medications for opportunistic diseases throug h the public
health system was heavily questioned, especially when
the policy was first implemented in the 1990s. The pro-
gram’s success is now acknowledged internationally, due
not only to this key component, but also to interaction
with other government ministries, in constant dialogue
with social movements and the scientific community.
Universal access to antiretroviral therapy has led to a
significant reduction in morbidity and mortality [2]. How-
ever, they have also widened changes in lipid metabolism
leading to hypertriglyceridemia, hypercholesterolemia
and other metabolic disorders, such as insulin resistance,
hyperglycemia and redistribution of body fat which are
risk factors in cardiovascular diseases [3]. These changes
are known as the lipodystrophy synd rome (HIVLS), offi-
cially described by the Food and Drug Administration
(FDA) in 1997, and also known as the syndrome of the
redistribution of body fat, or Metabolic Syndrome, asso-
ciated with an tiretrovir al therapy or, more recently, d ys li p i-
demic lipodystrophy associated with HIV/HAART [4-6].
Metabolic syndrome (MS) is a complex disorder rep-
resented by a set of cardiovascular risk factors commonly
associated with central adiposity and insulin resistance.
Metabolic Syndrome in People with HIV/AIDS
The importance of the epidemiological aspect, responsi-
ble for increased mortality cardiovascular estimated at
2.5 times, should be highlighted. Although MS still lacks
a well-established definition, there is a consensus indi-
cating that increased blood pressure, glucose metabolism
and lipid disorders and overweight are permanently asso-
ciated with increased cardiovascular morbidity and mor-
tality. The above has been observed in both developed
and developing countries. According to NCEP-ATP III,
MS represents the combination of at least three of the
following components, namely, abdominal obesity, tri-
glycerides > 150 mg/dL, low levels of HDL-cholesterol,
blood pressure > 130 mmHg, and fasting glucose > 110
mg/dL [7 ].
Few studies have been conducted in Brazil on MS in
patients with AIDS using HAART [8-11].
Current study evaluates the prevalence of metabolic
syndrome in HIV infected patients, from a two public
health Center for AIDS Care and Treatment in Parana,
southern Brazil.
2. Methodology
2.1. Study Setting and Design
One hundred and eighty-four patients with HIV/AIDS
were evaluated. The population under analysis consisted
of HIV/AIDS patients attended to at the 15th Regional
Health Unit in Maringa and at the 17th Regional Health
Unit in Londrina PR Brazil, covering 50 counties in the
north and northwestern region of the state of Paraná,
Brazil. The sample consisted of patients with at least a
five-year infection using antiretroviral therapy (HAART).
Patients were selected for the study after receiving the
required explanations on STD/AIDS at the nuclei of
Maringa and Londrina, and signed the consent form ap-
proved by the Committee for Ethics in Research involv-
ing Humans of the State University of Maringa. Survey
comprised a prevalence study with a convenience sample,
calculated by EpiInfo 5.5.1-2008 at a 90% confidence
2.2. Participant Recruitment and Data Collection
Socioeconomic data were collected by a closed question-
naire comprising age, duration of infection, family in-
come, education, alcohol/illegal drugs, use of antiretro-
viral drugs, rate of CD4 + T cells and the occurrence of
opportunistic infections. The interviews were individual,
previou sly schedu led, with an av erage dur ation of tw enty
Patients’ physical examination was subsequently per-
formed to determine fat percentage using a fat control
bio-impedance monitor Omron HBF 306 INT, and to de-
termine weight and height for Body Mass Index (BMI =
weight/height2). Height was measured by stadiometer
coupled to Welmy 200 with balance scale to the nearest
0.5 cm, with attached cursor for easy reading. Height de-
termination was performed by placing the patient bare-
foot on the base of the stadiometer, in an upright posture,
with feet together, arms pending down the body, touch-
ing the posterior surface of the body in scale measure-
Body weight was measured with leverage Welmy bal-
ance at 100 g precision. The patient was barefoot and
with as little clothing as possible. Patients were requested
to position themselves at the center of the scale platform
and remained upright, with arms down the body and
staring ahead so that no oscillations occurred at the time
of registration. The balance was checked before and after
weighing every ten patients.
The waist was measured in cm with an inelastic tape,
at midpoint between the iliac crest and the outer face of
the last rib. The hip was measured in centimeters with
inelastic tape at the iliac spine. Waist-hip ratio (WHR)
was obtained by the ratio between waist and hip circum-
Standardized assessments of blood pressure were con-
ducted using a validated automatic device (OMRON CP-
705), and the average of eight measurements in two of-
fice visits was used to diagnose hypertension.
So that metabolic parameters could be evaluated,
blood samples were collected after a 12-hour fast. Dosa-
ges were performed for fasting glycaemia, triglycerides,
total cholesterol, HDL-cholesterol and LDL-cholesterol.
All biochemical measurements were performed with
specific commercial kits using enzymatic colorimetric
method according to the manufacturer’s specifications.
2.3. Data Analysis
Data entry analysis was done by Graph Pad Prism pro-
gram 5.00 for frequency analysis, followed by chi-square
test at p < 0.05 significance level.
3. Results
3.1. Demographic Characteristics of Population
One hundred and eighty-four patients were evaluated.
Gender distribution comprised 51.5% males and 48.5%
females. Females’ age ranged between 26 and 64 years
(mean 42 years) and males’ age ranged between 20 and
56 (mean 40 years).
Further, 73.8% received primary education, 23% sec-
ondary education and 3% never attended school. Lowest
schooling occurred in females. Whereas 74% of females
had only attended elementary school, lack of schooling in
males reached 34%.
All patients were using HAART for at least five years.
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Metabolic Syndrome in People with HIV/AIDS
Open Access WJA
3.2. Frequency of Metabolic Abnormalities of
Biochemical changes in blood glucose occurred in 43 pa-
tients (23%), or rather, 16 (8%) females and 27 (15%)
Table 1 shows abnormalities in lipid levels. Abnormal
HDL cholesterol occurred in 114 (61.9%) patients, featu-
ring high risk rates, with no difference between males
and females. Regarding levels of blood triglycerides, 57
(30.9%) patients had high levels with no difference be-
tween male and female percentage.
Abdominal obesity was reported in 42 (23%) patients,
with no significant difference between males and females.
Table 2 shows the results of classification according to
Heyward & Stolarczyk [1 2].
Blood pressure was high in 23 (12.5%) patients, or
rather, 14 ( 7.6%) ma les and 9 (5% ) f emale s.
Table 3 shows fat percentage according to classifica-
tion by Pollock & Wilmore [13] with regard to CD4+
level, 71.4% registered rates ab ove 200 cells/mm3, where
as 28.6% of patients had rates equal to or below the
above rate.
Table 4 shows the prevalence of metabolic syndrome
in 55 (30%) patients, or rather, 30 (16.3%) males and 25
(13.7%) females. Metabolic Syndrome represents the
combination of least three components listed.
4. Discussion
Current research reinforces the occurrence, evidenced by
several authors, of HAART impact on the metabo lism of
lipids and glucose. Dyslipidemia associated with HAA-
RT was characterized by elevated levels of LDL-chole-
sterol and by low levels of HDL cholesterol. The above
alterations have been associated with the development of
atherosclerosis and its co mplications, such as myocardial
infarction and peripheral v a scular di s eas e [14,15].
Current results corroborate studies on the undisputed
importance of HAART with its high patient survival, but
also on the concomitant emergence of the SLHIV-asso-
ciated Metabolic Syndrome and its cardiovascular meta-
bolic risks [3]. Another metabolic alteration has been
reported in HIV lipodystrophy syndrome (SLD), known
as fat redistribution syndrome, which causes an accumu-
lation of fat in the dorso-cervical (buffalo hump) and
abdominal region. Fat redistribution with abdominal li-
pohypertrophy predisposes the patient to cardiovascular
disease risk due to visceral fat, directly associated with a
higher incidence of changes in serum lipids and insulin
resistance, with a rise in risks for the development of
Type 2 diabetes [16]. This study is well established as
shown in Table 2, classification of cardiovascular risk in
these patients have a higher prevalence of medium and
high risk. Most patients had fat percentage of average to
poor (Table 3).
Kramer et al. [17] reported that HIV dyslipidemia in
the HAART therapy patient is characterized by high
LDL-cholesterol and reduced level of HDL-cholesterol.
The authors also suggested that the factors that led pa-
tients to have HIV dyslipidemia are still not clearly elu-
cidated. No one knows for sure whether it is directly
caused by HAART or whether it is the product of several
factors such as antiretroviral therapy, genetic predisposi-
tion, diet and exercise, or such factors as host response to
HIV infection.
Farhi et al. [18] conducted a stud y at a university hos-
pital in Rio de Janeiro, Brazil, with 268 HIV patients and
concluded that in male patients the prevalence of dyslip-
idemia was higher when compared to that of females,
and that family history of dyslipidemia was directly re-
lated to the occurrence of dyslipidemia and the time of
the use of HAART by patien t s.
Research by Smith et al. [19] in São Paulo, Brazil,
with 319 patients divided into HIV HAART users and
non-users showed that the concentrations of total choles-
terol, triglycerides and glucose were significantly higher
among patients taking HAART. These data imply a high
prevalence of metabolic abnormalities, particularly high
levels of cholesterol and triglycerides, in patients treated
with HAART drug therapy.
Almeida [20] observed significant increases in total
cholesterol, triglycerides and glucose in 110 patients af-
ter treatment with HAART. Glucose levels increased as a
result of HAART in this study even though gender,
smoking, intravenous drug use and age did not cause
significance levels of total cholesterol, triglyceride and
glucose levels during treatment.
Although the main focus of metabo lic changes in HIV
patients is attributed to the side effects of HAART, stud-
ies from the pre-HAART condition established that HIV
Table 1. Prevalence of hyperglycemia, hypercholesterolemia and hypertriglyceridemia in HIV patients using HAART. n =
Patients HIV
n = 184 Glucose > 100 mg/dL CT > 200 mg/dL HDL < 50 mg/dL
or < 40 mg/dL LDL > 160 mg/dL TG > 150 mg/dL
n 43 47 114 82 57
% 23% 26% 61.9% 45% 30.9%
CT = Cholesterol Total, HDL = Cholesterol HDL, LDL = Cholesterol LDL, TG = Triglycerides.
Metabolic Syndrome in People with HIV/AIDS
Table 2. Cardiovascular risk classification according to the
relationship between waist and hips of HIV/AIDS patients.
n = 184.
Risk Classification n %
Low 32 17.4
Moderate 64 34.8
High 56 30.4
Towering 32 17.4
Classification of Heyward & Stolarczyk, 199 6.
Table 3. Classification of fat percentage in HIV/AIDS pa-
tients. n = 184.
Fat Percentage n %
Excellent 44 23.9
Well 13 7.1
Above media 44 23.9
Media 35 19
Bellow media 4 2.3
Bad 35 19.2
Very bad 9 4.6
Classification according to Pollock & Wilmore, 1993.
Table 4. Prevalence of metabolic syndrome in HIV/AIDS
patients. n = 184.
Metabolic Syndrome Parameters n %
Abdominal obes ity 52 28
Triglyceri de s > 15 0 mg/dL 57 30.9
< 50 mg/dL or < 40 mg/dL 114 61.9
Blood pressure > 130 mmHg 23 12.5
Glycaemia > 10 0 mg/dL 43 23
Metabolic syndr ome 55 30
infection itself would determine a more unfavorable lipid
profile with hypertriglyceridemia and low HDL-chole-
sterol. Constan et al. [21] included a prognostic implica-
tion of these changes, or rather, the lower the count of
CD4+, the greater are triglycerides levels and the lower
are HDL-cholesterol levels. The patho -physiology of this
association is not clear. There is still no consen sus on the
manner antiretroviral therapy enh ances this lipid disorder
and affects others associated with it, such as insulin re-
sistance, diabetes mellitus, central obesity and lipodys-
trophy. Our study showed that even with levels of CD4+
above 200 cells/mm3 found in a high alteration in levels
of triglycerides and HDL-cholesterol.
Current study shows that changes in blood levels of
HDL-cholesterol were high and corroborated the findings
of the above authors to explain these changes as a result
of the interaction HIV infection and antiretroviral ther-
Hsue et al. [22] retrospectively evaluated the risk fac-
tors and clinical outcome of 68 HIV patients hospitalized
between 1993 and 2003 for unstable angina or myocar-
dial infarction and compared the characteristics of this
population to a control group of 68 seronegative indi-
viduals with a diagnosis of acute coronary artery condi-
tion. The prevalence of smoking and low HDL-chole-
sterol was higher among HIV-positive patients, while in
the control group the prevalence for diabetes and dyslip-
idemia was higher. Although the rate of re-stenosis with
clinical manifestations was higher in patients with AIDS
and 29 angioplasties were performed in HIV-positive
patients, only 11 were performed in the control group. It
may be likewise inferred that low HDL-cholesterol may
be a significant cardiovascular risk factor in HIV pa-
Brazil and South Africa were among the first countries
profoundly impacted by the HIV/AIDS epidemic and had
similar rates of HIV infection in the early 1990s. Today,
Brazil has less than 1% adult HIV prevalence, imple-
mented treatment and prevention programs early in the
epidemic, and now has exemplary HIV/AIDS programs.
South Arica, by contrast, has HIV prevalence of 18% and
was, until recently, infamous for its delayed and inap-
propriate response to the HIV/AIDS epidemic. Although
Brazil has achieved so sui generis these indices mainly
due to free distribution of HAART may not be getting
adequately monitor these patients. Thirty years since the
first AIDS cases in Brazil few article related to appropri-
ate monitoring by health services and early identification
of patients with metabolic abnormalities inferring vul-
nerability increased.
5. Conclusion
In conclusion, the increasing number of antiretroviral
agents, longer duration of HAART use, and aging of the
HIV population, might contribute to the growing pre-
valence of metabolic syndrome and reduce the life ex-
pectancy of HIV-infected patients requiring political
strategy of care to this population in Brazil.
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