Children with HIV have additional challenges that should be addressed with formal practice guidelines, according to an editorial published online

-Team@CMHF

• Denise L Jacobson colleagues monitored trends in cholesterol and lipid levels in 240 children who had HIV and high cholesterol.
• During two years of follow-up, the children had persistently elevated lipid levels.
• Cholesterol levels were more likely to decrease in children whose antiretroviral drug therapy was changed during follow-up.
• Although the study did not include information on why their ART changed, in most cases it was likely to control HIV levels, not in response to high cholesterol levels.
• Just 15 of the children were started on cholesterol-lowering statin drugs.
• Margaret P Rhoads and colleagues compared the effects of different types of ART drugs on lipid levels in 449 children with HIV.
• All classes of ART drugs were associated with increased cholesterol — although the increases were most significant for children receiving one specific class of ART drugs (protease inhibitors).
• During the five-year follow-up period, 10% of the children developed low-density lipoprotein cholesterol levels above the 95th percentile.
• However, just three patients had cholesterol levels high enough to call for drug treatment.
• Taken together, these findings suggest that HIV-infected children have additional challenges that must be considered before changing ART regimens to improve lipoprotein profiles, including possibly switching lipid-lowering agents instead of ART regimens.
• One striking observation in the Jacobson study was the low percentage of children with hypercholesterolemia who initiated lipid-lowering medications, particularly Statins, and the time with which it took to initiate a medication after development of hypercholesterolemia.
• Rhoads and colleagues observed 20 children who may have met AAP criteria for pharmacologic intervention during the study period depending on associated risk factors; yet, no child received any lipid-lowering medications, which was attributed to a lack of cholesterol guidelines specific to children with HIV.
• While the AAP calls for statin use for healthy children with LDL-C levels less than 190 mg/dL only after dietary interventions have failed these guidelines likely are not relevant to HIV-infected children
• Ross and McComsey advocated a combined approach consisting of a lipid-friendly drug regimen along with nondrug treatments (such as diet and exercise).
• Statin use may be used in the future, not only to improve lipids, but also as a means of further decreasing inflammation.
• Similarly, biomarker monitoring or initiation of anti-inflammatory medications may also prove to be beneficial
• Formal guidelines are the first crucial step in minimizing CVD complications and maximizing quality of life in this vulnerable population.

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