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Dyslipidemias and Elevated Cardiovascular Risk on Lopinavir-Based Antiretroviral Therapy in Cambodia

  • Setha Limsreng ,

    Contributed equally to this work with: Setha Limsreng, Olivier Marcy

    Affiliation Hôpital Calmette, Phnom Penh, Cambodia

  • Olivier Marcy ,

    Contributed equally to this work with: Setha Limsreng, Olivier Marcy

    Current address: Univ. Bordeaux, Centre INSERM U1219, Bordeaux Populaion Health, Bordeaux, France

    Affiliations ESTHER Cambodia, Phnom Penh, Cambodia, Epidemiology and Public Health Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia

  • Sowath Ly,

    Affiliation Epidemiology and Public Health Unit, Institut Pasteur in Cambodia, Phnom Penh, Cambodia

  • Vara Ouk,

    Affiliation Hôpital Calmette, Phnom Penh, Cambodia

  • Hak Chanroeurn,

    Affiliation Hôpital Calmette, Phnom Penh, Cambodia

  • Saem Thavary,

    Affiliation Hôpital Calmette, Phnom Penh, Cambodia

  • Ban Boroath,

    Affiliation Hôpital Calmette, Phnom Penh, Cambodia

  • Ana Canestri,

    Affiliation Internal Medecine Department, Bicêtre Hospital, le Kremlin Bicêtre, France

  • Gérald Viretto,

    Affiliation ESTHER, Paris, France

  • Jean-François Delfraissy,

    Affiliation Internal Medecine Department, Bicêtre Hospital, le Kremlin Bicêtre, France

  • Olivier Ségéral

    Affiliation Internal Medecine Department, Bicêtre Hospital, le Kremlin Bicêtre, France

Dyslipidemias and Elevated Cardiovascular Risk on Lopinavir-Based Antiretroviral Therapy in Cambodia

  • Setha Limsreng, 
  • Olivier Marcy, 
  • Sowath Ly, 
  • Vara Ouk, 
  • Hak Chanroeurn, 
  • Saem Thavary, 
  • Ban Boroath, 
  • Ana Canestri, 
  • Gérald Viretto, 
  • Jean-François Delfraissy



Lopinavir/ritonavir (LPV/r) is widely used in Cambodia with high efficacy but scarce data exist on long-term metabolic toxicity.


We carried out a cross-sectional and retrospective study evaluating metabolic disorders and cardiovascular risk in Cambodian patients on LPV/r-based antiretroviral therapy (ART) for > 1 year followed in Calmette Hospital, Phnom Penh. Data collected included cardiovascular risk factors, fasting blood lipids and glucose, and retrospective collection of bioclinical data. We estimated the 10-year risks of coronary heart disease with the Framingham, Ramathibodi-Electricity Generating Authority of Thailand (Rama-EGAT), and the Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D) risk equations. We identified patients with LDL above targets defined by the French expert group on HIV and by the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group (IDSA-AACTG).


Of 115 patients enrolled—mean age 40.9 years, 69.2% male, mean time on LPV/r 3.8 years—40 (34.8%) had hypercholesterolemia (> 2.40 g/L), and 69 (60.0%) had low HDL cholesterol (< 0.40 g/L). Twelve (10.5%), 28 (24%) and 9 (7.7%) patients had a 10-year risk of coronary heart disease ≥ 10% according to the Framingham, D:A:D, and Rama-EGAT score, respectively. Fifty one (44.4%) and 36 (31.3%) patients had not reached their LDL target according to IDSA-AACTG and French recommendations, respectively.


Prevalence of dyslipidemia was high in this cohort of HIV-infected Cambodian patients on LPV/r. Roughly one third had high LDL levels requiring specific intervention.


HIV-related mortality has been dramatically reduced by the widespread use of antiretroviral treatment (ART). However, in developed countries the range of morbidity has increased, due to the emergence of cardiovascular and other non-AIDS related diseases. The role of dyslipidemia in cardiovascular morbidity is now well documented as well as the role of cardiovascular diseases as an important cause of death in HIV-infected patients [13]. These multifactorial complications are related to traditional risk factors including tobacco smoking, to the action of HIV itself via immune activation, as well as the toxicity of some antiretroviral drugs [4]. The role of several protease inhibitors in the occurrence of dyslipidemia is now well established and cumulative exposure to protease inhibitors has been robustly associated with a higher risk of myocardial infarction than in the general population [5].

In Cambodia, expanded access to ART has dramatically reduced morbidity associated with opportunistic infections [6], with excellent adherence and treatment outcomes [7, 8]. However, data on metabolic morbidity are limited. The expending use of ritonavir-boosted lopinavir (LPV/r) as second-line ART regimen could increase the risk of lipid disorders and contribute to an increased cardiovascular risk. Data on metabolic disorders in other South-East Asian patients on ART is scarce; high levels of dyslipidemias have been reported in Thai adults [9]. This study sought to assess the frequency of glucose and lipid metabolism disorders in Cambodian HIV-infected patients on LPV/r, and to assess their 10-year risk of developing coronary heart disease (CHD) according to the Framingham, D:A:D and Rama-Egat scoring systems [1012].


Study design, settings and patients

We conducted a cross-sectional study from November, 2010 to May, 2011, in the HIV cohort of the Calmette Hospital, Phnom Penh, Cambodia. Patient follow-up and management in the cohort has been described elsewhere [7, 13]. Routine metabolic monitoring included yearly fasting lipids. Fenofibrate was available for patients with triglycerides ≥5 g/l. Patients with either virologically confirmed ART-failure or repeated toxicities were switched from non-nucleoside reverse transcriptase inhibitor (NNRTI) to protease inhibitor-containing regimen. At the time of the study, LPV/r was the only PI routinely available in Cambodia.

Patients aged ≥ 18 years were eligible for inclusion if they had been on LPV/r for ≥ 12 months at the time of assessment. We excluded patients receiving statins in the private sector.

Study procedures and measurements

After written informed consent, patients underwent fasting lipids and glucose blood tests, complete physical examination with anthropometric measures, and a standardized questionnaire on demographic data and cardiovascular risk factors. Previous lipids and glucose measurements, CD4 count and plasma HIV RNA viral load, history of ART and other treatments were collected retrospectively from the patient's medical chart and/or the cohort database.

Ethical considerations

The study was approved by the Cambodian National Ethics Committee for Health Research. This study was conducted in accordance with the Declaration of Helsinki [14] and all patients signed the informed consent form prior to inclusion.


Hypercholesterolemia was defined as total cholesterol ≥ 2.4 g/l, low high-density lipoproteins cholesterol (HDL) as < 0.40 g/l, severe hypertriglyceridemia as triglycerides > 5g/l or receiving fenofibrate [15]. Elevated low-density lipoproteins cholesterol (LDL) was defined as ≥1.60 g/l, globally, and based on cardiovascular risk, individually. Hypertension was defined either as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥ 90 mmHg measured on both arms lying after 10-minute rest, or being on antihypertensive treatment. Diabetes mellitus was defined as either fasting glucose ≥ 1.26 g/l or being on antidiabetic treatment. Abdominal obesity was defined as waist circumference ≥ 90 cm in men and ≥80 cm in women which are measures recommended for Asian populations [16].

Individual 10 year risk of coronary heart disease (CHD) were calculated for each subject using the Framingham, D:A:D, and Rama-EGAT scoring systems, elaborated to predict the risk of angina pectoris, or myocardial infarction (MI) for the Framingham score, invasive coronary artery procedure, MI, or death from other CHD for the D:A:D score, and MI or invasive coronary artery procedure for the Rama-EGAT score [1012] (Table 1). For the D.A.D score, the 10-year cardiovascular risk was derived from the 1-year risk score, as proposed by the authors. 10-year cardiovascular risk was considered high when ≥20%. We also evaluated the proportion of patients who had not reached LDL levels recommended by the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group (IDSA-AACTG) [15], and the French expert group, as well as LDL levels requiring immediate initiation of statins, according to this latter. As recommended by the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group, patients were classified according to their level of cardiovascular risk based on their cardiovascular history, cardiovascular risk factors, and 10 year CHD risk calculated by the Framingham equation in four groups: 1) highest risk patients with either established CHD or CHD risk equivalent defined as diabetes mellitus or 10 year risk superior to 20% according to the Framingham score; 2) patients with 2 or more cardiovascular risk factors and a 10 year CHD risk of 10 to 20%; 3) patients with 2 or more cardiovascular risk factors and a 10 year CHD risk of 0 to 10%; 4) patients with 0 or 1 cardiovascular risk factors [15]. We estimated the proportion of patients having an LDL level above or equal to the optimal target and to the treatment decision threshold recommend for their cardiovascular risk group, respectively: 1) LDL goal 1.0 g/l and treatment decision threshold 1.3 g/l; 2) LDL goal and treatment decision threshold 1.3 g/l; 3) LDL goal 1.3 g/l and treatment decision threshold 1.6 g/l; 4) LDL goal of 1.6 and treatment decision threshold of 1.9 in patients with 0 or 1 CVRF [15]. We also evaluated the proportion of patients having reached the LDL target based on the cardiovascular risk classification proposed by the French recommendations [17]: 1) LDL 1.0 in highest risk patients with either established CHD or 3 CVRF; 2) 1.3 in patients with 2 CVRF; 3) 1.6 g/l in patients with 1 CVRF; 4) 1.9 in patients with 0 CVRF.

Table 1. Outcomes and predictors used in the Framingham, D:A:D, and Rama-EGAT scoring systems.

Lipodystrophy was defined as the presence of at least one sign graded as moderate or severe by the investigator among all the following signs, collected independently: fat loss in face, buttocks, arms and legs for lipoatrophy; the presence of "buffalo hump"-type fat deposits in upper back, increased breast size, and abdominal obesity for lipohypertrophy.

Statistical analyses

Comparisons between groups of patients were performed by Student t-test or non-parametric Kruskal-Wallis test for continuous variables, and Pearson chi-square or Fisher's exact test for categorical variables. Paired continuous variables were compared using Student's t test. Agreement between categorical classifications was measured by the kappa coefficient. All statistical comparisons were two-tailed, and P<0.05 was considered to be statistically significant. All analyses were performed using SAS version 11.1 (SAS Institute Inc, USA).


Patients characteristics

Of 1281 patients enrolled in the cohort, 173 (13.5%) were on LPV/r and 115 (66.5%) were enrolled in the study (Fig 1). The remaining patients were excluded because 41 had been on LPV/r ≤1 year and 15 were not seen during the study period. Additionally, 2 were excluded because they received statins.

Fig 1. Enrolment in the study.

ART: antiretroviral treatment; NNRTI: non-nucleoside reverse transcriptase inhibitors.

Patients had been on LPV/r for a median time of 4.0 years (Interquartile range (IQR) 2.5–5.0) (Table 2). None reported a history of CHD, peripheral vascular disease, or cerebrovascular accident. A total of 31 patients (27.0%) were taking fenofibrate, 11 (9.6%) were on antidiabetic, and 11 (9.6%) on antihypertensive medications. Demographic and HIV-related characteristics did not differ significantly between patients on fenofibrate or not.

Table 2. General characteristics, dyslipidemias, cardiovascular risk factors, risk of coronary heart disease at 10 years, and Low-Density Lipoprotein cholesterol levels based on cardiovascular risk in Cambodian HIV-infected patients on Lopinavir-based ART for 1 year or more (N = 115).

Dyslipidemias on lopinavir/ritonavir

Lipid profiles and prevalence of dyslipidemia are displayed in Table 2. Forty (34.8%) patients had hypercholesterolemia, 39 (33.9%) had high LDL, 69 (60.0%) had low HDL, and 33 (28.7%) had severe hypertriglyceridemia (> 5 g/L). Patients on fenofibrate had higher total cholesterol (2.56 ± 0.85 Vs. 2.18 ± 0.48, p 0.0027), lower HDL (0.34 ± 0.10 Vs. 0.41 ± 0.11, p 0.0012), and higher triglycerides (4.01 ± 2.31 Vs. 1.95 ± 1.07 p<0.0001). LDL did not differ between patients on fenofibrate and untreated patients (1.47 ± 0.80 Vs. 1.39 ± 0.47, p 0.4611).

At ART initiation, 58 (54.2%) patients out of 105 with HDL available had a low HDL. Only 70 patients had lipid levels available at ART initiation and ART switch from NNRTI to LPV/r based ART. LDL levels were measurable in 64 at ART initiation and 60 at ART switch. Comparisons between lipid levels at ART initiation and evaluation on LPV/r and between ART switch and evaluation on LPV/r are displayed in Table 3. Globally, from ART initiation to evaluation, total cholesterol increased by 0.60 ± 0.61 g/l, and LDL increased by 0.51 ± 0.62. On LPV/r, total cholesterol increased by 0.46 ± 0.68 g/l, LDL increased by 0.48 ± 0.64 g/l, and HDL decreased by 0.13 ± 0.41 g/l. In the 84 patients without fenofibrate, total cholesterol and LDL were increased compared to ART initiation levels (p <0.0001 and p <0.0001); however HDL and triglycerides were unchanged (p = 0.22 and p = 0.44).

Table 3. Evolution of lipid levels between ART-initiation of antiretroviral treatment, switch to lopinavir/ritonavir and evaluation (N = 70).

Cardiovascular risk and target LDL levels

Major cardiovascular risk factors are displayed in Table 2. When considering all risk factors exclusive of LDL, the median number of risk factor per patient was 1 (IQR: 0 to 2). 47 patients had only risk factor and 38 of them (80.9%) had isolated low HDL.

When assessing 10-year risk of CHD, 1 (0.9%), 11 (9.6%) and 0 (0%) patients were considered at high CHD risk by the Framingham, D:A:D and Rama-EGAT score, respectively. Additionally, following US recommendations, 20 patients with diabetes should be considered at high cardiovascular risk, raising the number to 21 (18.3%).

Twelve (10.5%), 28 (24%) and 9 (7.7%) patients were considered at intermediate or high 10-year risk of CHD by the Framingham, D:A:D, and Rama-EGAT score, respectively (Table 2). Individual characteristics of the patients considered at intermediate or high 10-year risk of CHD are showed on Table 4.

Table 4. Individual characteristics of patients at intermediate or high cardiovascular risk.

Fifty one (44.4%) and 36 (31.3%) patients had not reached their LDL target according to IDSA-AACTG and French recommendations, respectively (87.0% agreement, Kappa 0.73, SE 0.09, p<0.0001) (Table 5). Furthermore, 32 (27.8%) patients had LDL level requiring immediate treatment according to IDSA-AACTG (94.8% agreement with French target level, Kappa: 0.87, SE 0.09, p<0.0001). Of the 38 patients with isolated low HDL, 10 (26.3%) had not reached their LDL target according to IDSA–AACTG recommendations.

Table 5. Agreement between French recommendations and IDSA AACTG recommendations regarding achievement of / treatment decision based on LDL goal related to CV risk level.


Prevalence of dyslipidemias was high in this cohort of HIV-infected Cambodian patients on LPV/r based-regimen for a median duration of 4 years. Up to 42% of the patients were considered as having LDL higher than desired and 30% need immediate intervention including dietetic rules and treatment by statins.

Our findings were consistent with a previous report in Cambodia showing an overall prevalence of dyslipidemias of 73% after 4 years on ART, in a cohort with 10% of patients on LPV/r based ART. Total cholesterol is particularly high in our patients compared to other cohorts of HIV-infected patients on LPV/r [2, 19] but consistent with early report from the French APROCO cohort of patients on protease inhibitor-based ART before use of ritonavir boosting [20]. A more recent study in 170 Thai patients on PI-based ART reported a mean total cholesterol of 2.6 g/L and worsened lipid profiles anomalies in patients on ritonavir-boosted PI regimens [9]. Analysis of data collected routinely in cohort follow-up showed that total cholesterol, triglycerides, and LDL levels increased on LPV/r, a well known effect of this therapeutic regimen [19, 21, 22]. Our study, with 3 time points confirmed these results in a South-East Asian population.

HDL levels were low in our patients at ART initiation, which was expected, low HDL being a common HIV-induced dyslipidemia and possibly a main contributor to CHD risk in HIV-infected population [23]. Low HDL levels have been described in ART-naïve HIV-infected individuals in caucasian and other populations [2426]. Surprisingly, in our patients, HDL levels decreased on LPV/r whereas other studies reported an increase on ART [27]. This is of particular concern, even in the absence of other cardiovascular risk factors, as isolated low HDL has been shown to be associated to elevated cardiovascular risk in various studies [28] and specifically in Asian populations [29].

Hypercholesterolemia was 5 to 10-fold higher than estimated in a recent survey in the Cambodia general population which showed a global and urban hypercholesterolemia prevalence of 3.2% and 7%, respectively, using similar threshold or the presence of lipid lowering treatments [30]. Considering other risk-factors, reported tobacco smoking was much lower in our study compared to the general population survey which reported a 49.3% and 4.8% current smoking rate in men and women, and prevalence of hypertension and diabetes in the much higher than the 3.1 and 3.2% found in the survey, respectively. The prevalence observed in our study may have been overestimated due to the cross-sectional design, but the frequency of diabetes or antihypertensive medications intake confirmed the importance of these disorders.

The RAMA-EGAT score, specifically designed for a South-East Asian population, showed that cardiovascular risk was higher in this study than reported previously in Thai patients of similar age and duration on ART, including 60% on protease inhibitor-based ART [12]. Score performance for the prediction of 10-year cardiovascular risk differed from the study in Thailand which showed a good agreement between the D:A:D and the RAMA-EGAT scores, where in our study D:A:D predicted a higher cardiovascular risk in patients while Framingham and RAMA-EGAT scores had much lower estimates, which may be due to the high prevalence of diabetes.

The IDSA-AACTG and French scores agreed to identify roughly 1/3 of patients needing immediate treatment for LDL levels above the desired target. However statins are expensive and not widely available in setting such as Cambodia. Diet, lifestyle changes, and change of ART if 10-year CV risk > 20% seem to be the most appropriate solution [31]. Atazanavir, a newer protease inhibitor associated with only modest changes in lipid profile [32], is also becoming increasingly available in resource limited-setting and is recommended as first choice for second-line regimen since 2012 in Cambodia.

There are limitations to this study. First, patients from this single site may not be representative of the general HIV-infected population in Cambodia. As shown in other studies in Asia, lipid levels and cardiovascular risk in urban population may be different from rural population [33, 34]. We may also have overestimated hypertension and diabetes due to the essentially cross-sectional design of our study. Second, 27% of patients were on fenofibrate which may have led to decreased LDL and increased HDL levels. However the poor control of lipids emphasizes the interest for a better management of metabolic disorders in these patients. At last, none of the risk equations used in our study were validated specifically in HIV-infected South-East Asian populations. More epidemiological studies are needed to document incidence of cardio-vascular and other non-AIDS related morbidity in HIV-infected populations in South-East Asia and Africa. This would help validating risk equations and decision-making on risk reduction at individual level.

Dyslipidemias were frequent in HIV-infected Cambodian patients on LPV/r for more than one year, contributing to an elevated cardiovascular risk. The particularly high prevalence of low HDL warrants further investigation and better evaluation of cardiovascular risk in Asian population. In Cambodia, the progressive switch from LPV/r to atazanavir will certainly contribute to an improvement in lipid profiles and will need further evaluation. However, this study highlights the necessity to better take into account non-AIDS related co-morbidities in limited-resources settings as HIV care becomes chronic care and as these countries will face major challenges on management of cardiovascular morbidity in general [35].

Supporting Information

S1 Data. This is the S1 Data, which correspond to the entire data’s table of the study.



We thank the whole Calmette ESTHER team and especially Srun Chanvatey for his involvement in data management and collection and Pau Sam Aun who performed blood collections and helped enrolment in the study. We also would like to thank Anne-Marie Taburet, Anne Dulioust, Gilles Raguin, Chin Visal, Kong Sonya, and Chheang Ra for their support.

Author Contributions

  1. Conceived and designed the experiments: OS S. Limsreng JFD OM GV.
  2. Performed the experiments: S. Limsreng ST VO HC BB.
  3. Analyzed the data: S. Ly OM.
  4. Wrote the paper: OM S. Limsreng OS AC.


  1. 1. Lang S, Mary-Krause M, Cotte L, Gilquin J, Partisani M, Simon A, et al. Increased risk of myocardial infarction in HIV-infected patients in France, relative to the general population. AIDS (London, England). 2010;24(8):1228–30.
  2. 2. Aboud M, Elgalib A, Pomeroy L, Panayiotakopoulos G, Skopelitis E, Kulasegaram R, et al. Cardiovascular risk evaluation and antiretroviral therapy effects in an HIV cohort: implications for clinical management: the CREATE 1 study. Int J Clin Pract. 2010;64(9):1252–9. pmid:20653801
  3. 3. Lewden C, May T, Rosenthal E, Burty C, Bonnet F, Costagliola D, et al. Changes in causes of death among adults infected by HIV between 2000 and 2005: The "Mortalité 2000 and 2005" surveys (ANRS EN19 and Mortavic). Journal of Acquired Immune Deficiency Syndromes (1999). 2008;48(5):590–8.
  4. 4. Lake JE, Currier JS. Metabolic disease in HIV infection. The Lancet infectious diseases. 2013;13(11):964–75. pmid:24156897
  5. 5. Worm SW, Sabin C, Weber R, Reiss P, El-Sadr W, Dabis F, et al. Risk of myocardial infarction in patients with HIV infection exposed to specific individual antiretroviral drugs from the 3 major drug classes: the data collection on adverse events of anti-HIV drugs (D:A:D) study. The Journal of Infectious Diseases. 2010;201(3):318–30. pmid:20039804
  6. 6. Morineau G, Vun MC, Barennes H, Wolf RC, Song N, Prybylski D, et al. Survival and quality of life among HIV-positive people on antiretroviral therapy in Cambodia. AIDS Patient Care STDS. 2009;23(8):669–77. pmid:19591600
  7. 7. Ségéral O, Limsreng S, Nouhin J, Hak C, Ngin S, De Lavaissière M, et al. Three Years Follow-Up of First-Line Antiretroviral Therapy in Cambodia: Negative Impact of Prior Antiretroviral Treatment. AIDS Research and Human Retroviruses. 2011. doi: 10.1089/AID.2010.0125
  8. 8. Ferradini L, Laureillard D, Prak N, Ngeth C, Fernandez M, Pinoges L, et al. Positive outcomes of HAART at 24 months in HIV-infected patients in Cambodia. AIDS (London, England). 2007;21(17):2293–301.
  9. 9. Hiransuthikul N, Hiransuthikul P, Kanasook Y. Lipid profiles of Thai adult HIV-infected patients receiving protease inhibitors. Southeast Asian J Trop Med Public Health. 2007;38(1):69–77. pmid:17539249
  10. 10. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486–97. pmid:11368702
  11. 11. Friis-Møller N, Thiébaut R, Reiss P, Weber R, Monforte ADA, De Wit S, et al. Predicting the risk of cardiovascular disease in HIV-infected patients: the data collection on adverse effects of anti-HIV drugs study. Eur J Cardiovasc Prev Rehabil. 2010;17(5):491–501. pmid:20543702
  12. 12. Edwards-Jackson N, Kerr S, Tieu H, Ananworanich J, Hammer S, Ruxrungtham K, et al. Cardiovascular risk assessment in persons with HIV infection in the developing world: comparing three risk equations in a cohort of HIV-infected Thais. HIV Medicine. 2011;12(8):510–5. pmid:21375686
  13. 13. Ferradini L, Ouk V, Segeral O, Nouhin J, Dulioust A, Hak C, et al. High efficacy of lopinavir/r-based second-line antiretroviral treatment after 24 months of follow up at ESTHER/Calmette Hospital in Phnom Penh, Cambodia. J Int AIDS Soc. 2011;14.
  14. 14. Association WM. Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. 2008.
  15. 15. Dubé MP, Stein JH, Aberg JA, Fichtenbaum CJ, Gerber JG, Tashima KT, et al. Guidelines for the evaluation and management of dyslipidemia in human immunodeficiency virus (HIV)-infected adults receiving antiretroviral therapy: recommendations of the HIV Medical Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2003;37(5):613–27.
  16. 16. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112(17):2735–52. pmid:16157765
  17. 17. Yeni P. Prise en charge médicale des personnes infectées par le VIH. 2010 2010. Report No.
  18. 18. Dubé MP, Stein JH, Aberg JA, Fichtenbaum CJ, Gerber JG, Tashima KT, et al. Guidelines for the Evaluation and Management of Dyslipidemia in Human Immunodeficiency Virus (HIV)-Infected Adults Receiving Antiretroviral Therapy: Recommendations of the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group. Clinical Infectious Diseases. 2003;37(5):613–27. pmid:12942391
  19. 19. Domingo P, Suárez-Lozano I, Torres F, Teira R, Lopez-Aldeguer J, Vidal F, et al. First-line antiretroviral therapy with efavirenz or lopinavir/ritonavir plus two nucleoside analogues: the SUSKA study, a non-randomized comparison from the VACH cohort. J Antimicrob Chemother. 2008;61(6):1348–58. pmid:18356150
  20. 20. Savès M, Raffi F, Capeau J, Rozenbaum W, Ragnaud J-M, Perronne C, et al. Factors related to lipodystrophy and metabolic alterations in patients with human immunodeficiency virus infection receiving highly active antiretroviral therapy. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2002;34(10):1396–405.
  21. 21. Meynard J-L, Lacombe K, Poirier J-M, Massot O, Lefebvre B, Bouchaud O, et al. Sustained increase of HDL cholesterol over a 72-week period in HIV-infected patients exposed to an antiretroviral regimen including lopinavir/ritonavir. J Int Assoc Physicians AIDS Care (Chic Ill). 2008;7(6):311–6.
  22. 22. Eron J Jr, Yeni P, Gathe J Jr, Estrada V, DeJesus E, Staszewski S, et al. The KLEAN study of fosamprenavir-ritonavir versus lopinavir-ritonavir, each in combination with abacavir-lamivudine, for initial treatment of HIV infection over 48 weeks: a randomised non-inferiority trial. Lancet. 2006;368(9534):476–82. pmid:16890834
  23. 23. Cotter AG, Satchell CS, O'Halloran JA, Feeney ER, Sabin CA, Mallon PWG. High-density lipoprotein levels and 10-year cardiovascular risk in HIV-1-infected patients. AIDS (London, England). 2011;25(6):867–9.
  24. 24. Rose H, Woolley I, Hoy J, Dart A, Bryant B, Mijch A, et al. HIV infection and high-density lipoprotein: the effect of the disease vs the effect of treatment. Metab Clin Exp. 2006;55(1):90–5. pmid:16324925
  25. 25. Anastos K, Ndamage F, Lu D, Cohen MH, Shi Q, Lazar J, et al. Lipoprotein levels and cardiovascular risk in HIV infected and uninfected Rwandan women. AIDS Research and Therapy. 2010;7(1).
  26. 26. Fourie CMT, Van Rooyen JM, Kruger A, Schutte AE. Lipid abnormalities in a never-treated HIV-1 subtype C-infected African population. Lipids. 2010;45(1):73–80. pmid:19916038
  27. 27. Stein JH, Komarow L, Cotter BR, Currier JS, Dubé MP, Fichtenbaum CJ, et al. Lipoprotein Changes in HIV-Infected Antiretroviral-Naïve Individuals after Starting Antiretroviral Therapy: ACTG Study A5152s Stein: Lipoprotein Changes on Antiretroviral Therapy. J Clin Lipidol. 2008;2(6):464–71. doi: 10.1016/j.jacl.2008.08.442
  28. 28. Boden WE. High-density lipoprotein cholesterol as an independent risk factor in cardiovascular disease: assessing the data from Framingham to the Veterans Affairs High—Density Lipoprotein Intervention Trial. The American Journal of Cardiology. 2000;86(12A):19L–22L. pmid:11374850
  29. 29. Huxley RR, Barzi F, Lam TH, Czernichow S, Fang X, Welborn T, et al. Isolated Low Levels of High-Density Lipoprotein Cholesterol Are Associated With an Increased Risk of Coronary Heart Disease: An Individual Participant Data Meta-Analysis of 23 Studies in the Asia-Pacific Region. Circulation. 2011;124(19):2056–64. pmid:21986289
  30. 30. Oum S, Prak PR, Khuon EM, Mey V, Aim S, Bouchan Y, et al. Prevalence of Non-Communicable Disease Risk Factors in Cambodia. STEPS Survey, Country Report, September 2010. Ministry Of Health—UNiversity of Health Sciences, Phnom Penh, 2010 2010/09. Report No.
  31. 31. European Aids Clinical Society. European AIDS Clinical Society Guidelines—Version 6—October 2011. 2011 2011/10//. Report No.
  32. 32. Molina J-M, Andrade-Villanueva J, Echevarria J, Chetchotisakd P, Corral J, David N, et al. Once-daily atazanavir/ritonavir compared with twice-daily lopinavir/ritonavir, each in combination with tenofovir and emtricitabine, for management of antiretroviral-naive HIV-1-infected patients: 96-week efficacy and safety results of the CASTLE study. Journal of acquired immune deficiency syndromes (1999). 2010;53(3):323–32.
  33. 33. Pongchaiyakul C, Hongsprabhas P, Pisprasert V, Pongchaiyakul C. Rural-urban difference in lipid levels and prevalence of dyslipidemia: a population-based study in Khon Kaen province, Thailand. J Med Assoc Thai. 2006;89(11):1835–44. pmid:17205863
  34. 34. Gupta R, Deedwania PC, Sharma K, Gupta A, Guptha S, Achari V, et al. Association of educational, occupational and socioeconomic status with cardiovascular risk factors in Asian Indians: a cross-sectional study. PLoS ONE. 2012;7(8).
  35. 35. World Health Organization, World Heart Federation, World Stroke Organization. Global atlas on cardiovascular disease prevention and control. Geneva: World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization; 2011. 155 p.