Highly Active Antiretroviral Therapy (HAART) and Metabolic Complications

The overwhelming impact the Human Immunodeficiency Virus (HIV) has on the world is undeniable – by the end of 2009 there were 33.3 million people living with HIV in the world, with 1.8 million deaths in that year alone (WHO 2010). In addition, the high rate of deaths can be directly attributed to the lack of available medications – only 36% of the infected population received adequate antiretroviral therapy (WHO 2009). Besides the known political and monetary issues at hand, the multiple number of HIV virus subtypes and subsubtypes that have been described are overwhelming pharmaceutical availability. In fact, most research completed on HIV therapies has occurred, and continues to occur, in Europe and America, targeting the HIV-1 strain, although much of the world population is also afflicted by HIV-2. To combat viral strain mutations, Highly Active Antiretroviral Therapy (HAART) has increased in complexity and effectively decreased deaths from opportunistic infections in those that are candidates for this treatment. However, these advances are tainted with metabolic long-term side effects, some of which are directly attributed to HIV Protease Inhibitors (PIs). HAART has been linked to cardiovascular complications in HIV-1 patients, and recent studies have shown that HIV PIs play critical roles in insulin resistance, dysregulation of lipid metabolism, and inflammation, which are all cornerstones of cardiovascular complications. In addition, HIV PI-induced atherosclerotic cardiovascular disease is becoming the leading cause of mortality in HIV-1 infected persons in developed countries. During the last decade, an extensive effort has been put forth to study HAART-induced side effects. Both in vitro and in vivo animal studies from our laboratory and others’ have linked HIV PIs with the activation of endoplasmic reticulum (ER) stress and oxidative stress as well as an increase in inflammatory cytokine production from several cell types including macrophages, hepatocytes, intestinal epithelial cells and adipocytes. However, the underlying cellular and molecular mechanisms remain to be fully identified and therapeutic strategies are currently unavailable. Understanding the root causes of HAART-associated metabolic syndrome and its potential implications for HIV-infected patients will be critical to the design of effective interventions to combat the metabolic and cardiovascular diseases