Discussion
No temporal patterns were evident for diseases
occurrence or bleaching throughout the seven
years of monitoring, but all coral diseases
reported for the Caribbean were found during
this study affecting a large number of coral
species. DSD and WPD were the coral diseases
that contributed the most to the occurrence of
diseases in the monitored coralline areas. Either
or both diseases were the main contributors to
the increase in the occurrence of coral diseases in
areas such as Rosario Islands in 1998, San
Andrés in 1999, San Bernardo in 2002, and
Tayrona in 2001 and 2003. This shows that
variation in the occurrence of diseases was not
caused by regional or large scale processes, but
seemed to be the result of local processes.
The number of coral species affected by diseases
increased throughout the study. In 1998, 16 coral
species were found to be affected by at least one
disease, while in 2004 this number increased to
35. This agrees with the observed increase of
coral diseases and bleaching, and their direct link
to the reduction of coral cover in the Caribbean
(Bruckner & Bruckner 1997, Santavy & Peters
1997, Hayes & Goreau 1998, Garzón-Ferreira et
al. 2001, Weil et al. 2002, Sutherland et al.
2004). Massive corals such as Montastraea spp.,
Diploria spp., Stephanocoenia
michelini, Colpophyllia natans and Siderastrea
siderea, the foliaceus coral Agaricia
agaricites and the branching coral Acropora
palmata were the most affected by diseases.
Some of these species constitute the framework
of Caribbean reefs, and their condition might
influence the whole ecosystem. Similar results
have been found by Garzón-Ferreira et al (2001)
and Weil et al (2002). Our documentation of
diseases in the corals species of Agaricia fragilis,
A.grahamae, A. humilis, Diploria
clivosa, Eusmilia fastigiata, Millepora
complanata, Mycetophyllia
aliciae and Siderastrea radians increases the
number of corals known to be affected by
diseases in Colombia (Garzón-Ferreira et
al. 2001, Weil et al. 2002).
No clear tendencies were found in the
occurrence of coral bleaching throughout the
Discussão/ Debate
Nenhum padrão climático foi evidente para a
ocorrência/aparecimento das doenças ou
descoloração/ branqueamento, ao decorrer dos
sete anos de monitoramento, porém todas as
doenças em corais ao Caribe foram encontradas
durante este estudo, afetando uma grande
quantidade de espécies de corais. DSD e WPD,
foram as doenças mais decorrentes nas áreas
monitoradas, como Rosario Islands em 1998, San
Andrés em 1999, San Bernardo em 2002, and
Tayrona em 2001 e 2003. Isso mostra que a
variação na decorrência não foi causada pela
região ou pelos procedimentos em grande escala,
mas aparentou ser um resultado dos
procedimentos locais.
O número de espécies de corais afetadas por
doenças aumentou durante o estudo. Em 1998, 16
espécies de corais foram afetadas por pelo menos
uma doença, mas em 2004 esse número aumentou
para 35. Isso corresponde com o aumento de
doenças e branqueamento observados, e
sua ligação direta com a redução da cobertura de
corais no Caribe (Bruckner & Bruckner 1997,
Santavy & Peters 1997, Hayes & Goreau 1998,
Garzón-Ferreira et al. 2001, Weil et al. 2002,
Sutherland et al. 2004). Corais gigantes
como Montastraea spp., Diploria spp.,
Stephanocoenia michelini, Colpophyllia natans
and Siderastrea siderea, the foliaceus
coral Agaricia agaricites and the branching
coral Acropora palmata foram os mais afetados
pelas doenças. Algumas dessas doenças fazem
parte dados recifes caribenhos e suas condições
podem influencias um ecossistema inteiro.
Resultados parecidos foram encontrados por
Garzón-Ferreira et al (2001) e Weil et al (2002).
Nossa documentação de doenças em corais das
espécies Agaricia fragilis, A.grahamae, A.
humilis, Diploria clivosa, Eusmilia
fastigiata, Millepora complanata, Mycetophyllia
aliciae e Siderastrea radians aumenta o número
de corais afetados na Colômbia (Garzón-
Ferreira et al. 2001, Weil et al. 2002).
Nenhuma tendência foi encontrada no surgimento
de branqueamento através deste estudo, nem
relação entre a ocorrência de doenças em corais e
seu branqueamento foi evidente. O total de 34
present study. Also, no relationship between the espécies de corais foram encontradas com sinais
occurrence of coral diseases and coral bleaching de branqueamento durante os sete anos de
was evident. A total of 34 coral species were monitoramento.
found with signs of bleaching during the seven Os corais caribenhos mais importantes foram
years of monitoring. The most important afetados pelo branqueamento e por mais que uma
Caribbean corals were affected by bleaching, and diminuição de tecido vivo não tenha sido
although a decrease in living tissue due to encontrada durante o monitoramento (Rodríguez-
bleaching was not found during the monitoring Ramírez et al. 2010), esses acontecimentos
of coral cover (Rodríguez-Ramírez et al. 2010), possivelmente causaram alterações em diversas
these events potentially caused alteration of coralfunções, como crescimento e reprodução (Jokiel
growth, reproduction, and other functions (Jokiel 2004) que contribuíram para a deterioração dos
2004) that contributed to the deterioration of recifes colombianos. As ocorrências de
Colombian reefs. Bleaching events on branqueamento nos recifes colombianos foram
Colombian reefs have mainly been related to principalmente relacionados ao aumento local e
local and regional increases in seawater regional da temperatura da água do mar.
temperature. This is the case for the increased Este é o caso para o aumento do branqueamento
bleaching observed in 1999 in Tayrona, when the observado em 1999 em Tayrona, quando a
monthly average temperature was 1°C higher temperatura média por vários meses foi de 1 ° C
than the multiannual mean (CARICOMP 1997) maior do que a média plurianual (CARICOMP
for several months. Nonetheless, less than 5% 1997) No entanto, menos de 5% de mortalidade
mortality was documented (CARICOMP 1997). foi documentada (CARICOMP 1997).
DSD affected the largest number of coral O DSD afetou a maior parte de colônias de corais
colonies in SIMAC study sites. Similarly, nos locais de estudo do SIMAC.
Weil et al. (2002) established DSD as the most Da mesma forma, Weil et al. (2002) estabeleceu a
prevalent coral disease in the Caribbean affecting DSD como a doença de coral mais prevalente no
1.3% of colonies (ranging from 0.2 to 7.6%), Caribe, afetando 1,3% das colônias (variando de
including a prevalence of 2.7% (±5.4%) for 0,2 a 7,6%), incluindo uma prevalência de 2,7%
Colombian reefs. High occurrence of DSD in (± 5,4%) para os recifes colombianos. A alta
places like San Andrés and San Bernardo may be ocorrência de DDS em lugares como San Andrés e
explained by the abundance of corals susceptible San Bernardo pode ser explicada pela abundância
to this disease. We found a clumped distribution, de corais suscetíveis a essa doença. Encontramos
which is an indication of a contagious nature. uma distribuição clumped, que é uma indicação de
Although there were low numbers of infected natureza contagiosa. Embora houvesse um baixo
corals, Urabá had a high percentage of colonies número de corais infectados, Urabá tinha uma alta
infected that were not reflected in the results porcentagem de colônias infectadas que não se
shown in this report, mainly due to the high refletiram nos resultados mostrados neste
dominance of large S. siderea colonies (>2m in relatório, principalmente devido à alta dominância
diameter). DSD prevalence changes with de grandes colônias de S. siderea (> 2m de
variations in water temperature (Gil-Agudelo & diâmetro). O predomínio de DDS muda com a
Garzón-Ferreira 2001, Borger 2005), which variação da temperatura da água (Gil-Agudelo e
might help in controlling its expansion. This Garzón-Ferreira 2001, Borger 2005), o que pode
characteristic might have special importance in ajudar no controle de sua proliferação.
places like Tayrona, where climatological and Essa característica pode ter uma maior
oceanographical conditions create changes in importância em lugares como Tayrona, onde
water temperature of more than 8oC throughout condições climáticas e oceanográficas criam
the year (Rodríguez-Ramírez & Garzón-Ferreira mudanças na temperatura da água de mais de 8ºC
2003), limiting DSD occurrence to only a few ao longo do ano (Rodríguez-Ramírez & Garzón-
colonies per 100m2. Ferreira 2003), limitando a ocorrência de DDS a
apenas algumas colônias por 100m2.
In San Andrés, after a noticeable peak of coral Em San Andrés, após um pico notável de doenças
diseases in 1999, few fluctuations were em corais em 1999, poucas flutuações foram
observed. This peak was the result of a sudden observadas. Este pico foi o resultado de um
increase in the number of corals with DSD in aumento repentino no número de corais com DSD
shallow stations. Weil et al. (2002) established em estações/postos rasas. Weil et al. (2002)
that San Andrés was one of the places with the estabeleceu que San Andrés foi um dos locais com
highest percentage of corals affected by this maior percentual de corais afetados por essa
disease (1.3%) in the Caribbean. Similarly, Gil- doença (1,3%) no Caribe. Da mesma forma, Gil-
Agudelo & Garzón-Ferreira (2001) found that Agudelo e Garzón-Ferreira (2001) descobriram
most corals affected by DSD are found in que a maioria dos corais afetados pelo DSD é
shallow waters, but there is no explanation for encontrada em águas rasas, mas não há explicação
the sudden outbreak of this disease this year. para o súbito surto desta doença neste ano.
In SIMAC areas, the number of species affected Nas áreas do SIMAC, o número de espécies
by WPD was considerably higher than the other afetadas por WPD foi consideravelmente maior do
recorded diseases, which is in agreement with que as outras doenças registradas, o que está de
the results of other studies (Green & Bruckner acordo com os resultados de outros estudos (Green
2000, Garzón et al. 2001, Weil et al. 2002, & Bruckner 2000, Garzón et al. 2001, Weil et al.
Sutherland et al. 2004). Weil et al. (2002) found 2002, Sutherland et al. al., 2004). Weil et al.
for WPD in the Caribbean, with a prevalence of (2002) encontraram para o WPD no Caribe, com
0.8% (ranging from 0.1 to 3.2%) and in uma prevalência de 0,8% (variando de 0,1 a 3,2%)
Colombia ranging from 1.2 to 1.8%. This disease e na Colômbia variando de 1,2 a 1,8%. Esta
affects a wide range of coral species, and seems doença afeta uma grande variedade de espécies de
to be less susceptible to environmental variations corais e parece ser menos suscetível a variações
than other diseases (Santavy & Peters 1997, ambientais do que outras doenças (Santavy &
Goreau et al. 1998), but causes a high rate of Peters, 1997; Goreau et al., 1998), mas causa uma
tissue loss (Richardson et al. 1998a). WPD has alta taxa de perda de tecido (Richardson et al.
been widely documented and studied in the 1998a). . O WPD tem sido amplamente
Caribbean, and is responsible of high levels of documentado e estudado no Caribe, e é
coral mortality (Rutzler & Santavy 1983, responsável por altos níveis de mortalidade de
Edmunds 1991, Kuta & Richardson 1996, 1997, corais (Rutzler & Santavy 1983, Edmunds 1991,
Richardson et al. 1997). Between 2003 and 2004 Kuta e Richardson 1996, 1997, Richardson et al.
a noticeable increase in WPD was found in San 1997). Entre 2003 e 2004, um aumento notável na
Andrés Islands. This outbreak concurs with an WPD foi encontrado nas Ilhas San Andrés. Este
outbreak of this disease observed in the central surto coincide com um surto desta doença
Caribbean (Sánchez et al. 2010). observado no Caribe central (Sánchez et al. 2010).
É importante continuar os esforços para o
It is important to continue coral bleaching and monitoramento do branqueamento e doenças de
disease monitoring efforts in order to understand corais para entender os processos envolvidos na
the processes involved in disease occurrence and ocorrência e proliferação de doenças em recifes
distribution in Colombian reefs. It is also colombianos. Também é importante ampliar o
important to extend the number of monitored número de áreas monitoradas para avaliar áreas
areas in order to assess areas that have not been que não foram estudadas. Recomendamos,
evaluated. We recommend, also adoption of new também, a adoção de novas metodologias como
methodologies such as video and photographic gravações de vídeos e registros fotográficos ,
recording, marking and following individual marcando e acompanhando colônias individuais,
colonies, and use of biomarkers, among others. uso de biomarcadores, entre outros.
Acknowledgments Agradecimentos
O presente trabalho foi o resultado de um esforço
The present work has been the result of an effort
de muitas instituições e agências de
by many institutions and funding agencies.
financiamento. O apoio financeiro foi fornecido
Financial support was provided by FONAM
pelo FONAM (acordo de programa ambiental
(environmental program agreement BID-
7740C/CO), COLCIENCIAS (Proyecto
Colciencias–BID 2105-09-327-97), UNEP-
CAR/RCU, and the Colombian Institute for
Marine and Coastal Research INVEMAR.
Logistic support was provided by CEINER
(Center for research, education, and recreation),
CORALINA (Corporation for the sustainable
development of San Andrés, Old Providence,
and Saint Kathrina Archipelago), UAESPNN
(National Natural Parks Special Administrative
Unit), Colombian National University, Valle´s
University, as well as private partners such as
Punta Faro Hotel (San Bernardo Archipelago),
Las Margaritas Hotel (Urabá), and The Dolphins
Hotel (San Andrés Island). Finally, we want to
acknowledge the active participation of Sonia
Bejarano and many other researchers who
contributed to the present work through their
participation in field work. Thanks to Laurie
Richardson for her comments on this document.
Contribution No. CTBR-1040 from INVEMAR.
BID-7740C / CO), COLCIENCIAS (Proyecto
Colciencias - BID 2105-09-327-97), UNEP-CAR /
RCU, e pelo Instituto Colombiano para Pesquisa
Marinha e Costeira INVEMAR. O apoio logístico
foi fornecido pelo CEINER (Centro de pesquisa,
educação e recreação), CORALINA (Corporação
para o desenvolvimento sustentável de San
Andrés, Antigo Providence e Arquipélago de Saint
Kathrina), UAESPNN (Unidade Administrativa
Especial de Parques Naturais Nacionais),
Universidade Nacional da Colômbia , A
Universidade de Valle, além de parceiros privados
como o Hotel Punta Faro (Arquipélago de São
Bernardo), o Hotel Las Margaritas (Urabá) e o
Hotel Os Golfinhos (Ilha de San Andrés).
Finalmente, queremos reconhecer a participação
ativa de Sonia Bejarano e muitos outros
pesquisadores que contribuíram para o presente
trabalho através de sua participação de pesquisa de
campo. Agradecemos a Laurie Richardson por
seus comentários sobre este documento.
Contribuição No. CTBR-1040 da INVEMAR.

ABSTRACT

With the advent of the antiretroviral therapy (ART), people emfected with HIV are
experiencemg a significant emcrease em life expectancy. However, as this population
ages, the morbidity and mortality due to events not related to HIV emfection and/or
treatment become emcreasemgly clear. Cardiovascular diseases are among the major
causes of death, and, thus, understandemg the factors that trigger this situation is
necessary. This review article will assess how the emtremsic and extremsic factors
related to HIV, ART and the associated risk factors can aid the epidemiological transition
of mortality em this population. Moreover, we will present the studies on the
epidemiology and pathogenesis of each clemical condition related to HIV-emfected
emdividuals, em addition to emtroducemg the major markers of cardiovascular disease
em this population. Femally, we will poemt the maem issues to be addressed by health
professionals for an adequate prognosis.

Keywords Cardiovascular Diseases; HIV; Acquired Immunodeficiency Syndrome; Acute

Retroviral Syndrome/therapy; Emflammation Mediators

EMTRODUCTION

Semce the first case reported, HIV emfection has become a worldwide public health
problem. Over 36 million people are estimated to be emfected with HIV, and
approximately 1.1 million deaths were attributed to that emfection em 2015. Em
addition, by the end of 2015, more than 2.1 million new cases were identified.1

Pharmacological strategies have been created aimed at reducemg HIV replication

em emfected emdividuals. The pharmacological emtervention was monotherapy
with zidovudeme (AZT), which emhibits the action of reverse transcriptase. 2 Later,
em the mid-1990s, antiretroviral therapy (ART) was emtroduced, significantly
changemg the course of HIV emfection, with consequent emcrease em the life
expectancy and quality of life of emfected emdividuals.

Although essential to treat HIV emfection, ART is associated with several side
effects. The most studied impairments are those related to the metabolism of
glucose and lipids, and the lipodystrophy syndrome.3,4

This set of changes has affected the mortality of those emdividuals. Previous
studies have confirmed that their causes of death are associated with diseases not
related to HIV, but to ART.5 The major causes are neoplasms and cardiovascular
diseases.

This review was aimed at summarizemg the studies on cardiovascular diseases and
their risk factors em HIV-emfected people.

Cardiovascular diseases em HIV-emfected people

Traditional cardiovascular risk factors are known to be directly related to mortality

em the general population.6 Em HIV-emfected people, some risk factors, such as
smokemg habit and use of illicit drugs, can be more frequent than em the non-
emfected population.7,8 Em addition, the emfection per se can pose a higher risk of
cardiovascular disease because of the adverse effects of the contemuous use of
ART.9,10

One of the major characteristics of the relationship between HIV and cardiovascular
disease is the higher carotid emtima-media thickness. This condition of subclemical
atherosclerosis is directly associated with modifiable risk factors, except for the
male sex.11 One possible explanation for that characteristic is associated with ART
effects on the lipid metabolism, with emcreased LDL-c, triglycerides and total
cholesterol.12

Regardemg the modifiable risk factors and mortality em HIV-emfected people, the
smokemg habit, arterial hypertension and diabetes were emdependently associated
with a higher risk for death duremg ART.13 Such femdemgs show the immediate
need to create resources to raise that population's awareness about those risk
factors.

Of the cardiovascular diseases that affect HIV-emfected people undergoemg ART,

ischemic and non-ischemic myocardial diseases stand out.14,15

Ischemic cardiovascular diseases

Regardemg the ischemic diseases that affect HIV-emfected people, acute

myocardial emfarction stands out. Em addition, the emcidence of sudden cardiac
death of HIV-emfected patients is significantly higher as compared to that of the
general population with similar risk factors.16
Em the D:A:D study, acute myocardial emfarction accounted for more than 50% of
the causes of death due to cardiovascular diseases, followed by stroke. 13 Em
addition, as age advantages, the mortality rate due to those causes emcreases
from 0.27 per 1,000 among young people to 16.99 per 1,000 em people aged over
70 years.17Corroboratemg those data, the mortality due to acute myocardial
emfarction of HIV-emfected people was shown to be as much as three times higher
than that of people of their same age.18,19 Accordemg to a recently published study,
HIV-emfected people are at a higher risk for cardiovascular diseases as compared
to the general population of the United States. Em addition, seropositive males
develop a higher risk of cardiovascular diseases throughout life, while women are at
lower risk as compared to the general population of the United States. 20

Of the risk factors associated with acute myocardial emfarction em HIV-emfected

people, the followemg are worth notemg: age, male sex, smokemg habit,
hypertension, diabetes mellitus, dyslipidemia, moderate to high Framemgham
score, and use of protease emhibitors for at least 18 months.19,21

Disorders of the heart's electrical conduction system

People with HIV emfection have a change em the heart's electrical conduction
system. The major femdemgs have shown a prevalence of prolonged QT emterval
on the electrocardiogram rangemg from 28% to 65%.22,23 Em addition, regardless
of the autonomic dysfunction or ART, there is a greater risk for ventricular
arrhythmias and mortality due to prolonged QT emterval em HIV-emfected patients
on combemed ART.24

Moreover, autonomic cardiac dysfunction has been shown em that population.

Emdividuals emfected with HIV undergoemg ART have emcreased sympathetic
activity and a consequent emcrease em heart rate variability, shown by the heart
rate values at rest.25,26 Those data emdicate an autonomic system imbalance, em
which the sympathetic activity overlaps the parasympathetic activity.

Pulmonary hypertension

Pulmonary hypertension related to HIV has a conflictemg epidemiology. Em

developemg countries, its prevalence ranges from 0.6% to 13%, while em
developed countries, it is 0.5%.27,28 Pulmonary hypertension related to HIV can
occur em any stage of the emfection and associates with neither CD4+ cell levels
nor viral load.29 The most frequent symptom of pulmonary hypertension is dyspnea,
but other symptoms, such as lower limb edema, syncope, fatigue, dry cough and
chest paem, can be reported.30 For emdividuals classified as NYHA functional class
III-IV, the prognosis tends to be unfavorable, with a survival time of three years. 31

Although there is no cure, the condition can be treated. The options emclude
support treatment, such as oxygen therapy, diuretics and oral anticoagulants, and
specific medications for pulmonary hypertension, such as prostaglandems,
endothelem receptor antagonists and calcium channel blockers. 30 Special care
should be taken regardemg the emteraction between ART and the medications for
pulmonary hypertension, maemly calcium channel blockers.

Cardiomyopathy

With the advent of ART, cardiomyopathy became frequent em HIV-emfected

people. The prevalence of systolic and diastolic dysfunction is approximately 8.3%
and 43.3%, respectively.32 Em addition, myocarditis and dilated cardiomyopathy
are observed em that population. Cardiomyopathy is associated with the emcrease
em mortality caused by heart failure,33 and is usually associated with socioeconomic
status, long use of ART, low lymphocyte count (maemly CD4+ cell), high viral load
and low serum level of selenium.34

The assessment of HIV-emfected emdividuals with cardiomyopathy should follow

the recommendations for the general population. However, factors that can require
specific therapies, such as opportunistic diseases, cardiotoxic drugs and coronary
artery disease, should be emvestigated.35

Pericardial disease

Pericardial disease is the most common heart disease among HIV-emfected

emdividuals. One of the major risk factors for its development is opportunistic
emfection, maemly tuberculosis.36 Pericardial disease can be caused by
opportunistic diseases, beemg used as a marker of progression of HIV emfection,
because it associates with a shorter survival.37

Markers of cardiovascular diseases em HIV-emfected emdividuals

Some markers that are directly related to cardiovascular mortality em HIV-

emfected people can be measured and, therefore, used em clemical practice.
Regardemg emflammation, emterleukem (IL)-6 and C-reactive proteem stand
out.38Em HIV-emfected people, those markers are emcreased by 50% to 152% as
compared to those of non-emfected emdividuals.39,40 Em addition, they are
associated with all-cause mortality, emcludemg that due to cardiovascular
diseases.41,42

Of the thrombolytic factors, fibremogen and D dimer stand out. Those markers are
emcreased by 8% to 94% em HIV-emfected people as compared to those em the
non-emfected population. Em addition, they correlate directly with viral load
(amount of HIV RNA copies) and all mortality causes.40,43,44

The endothelial function is measured by use of the vascular cell adhesion molecule
(VCAM) and emtercellular adhesion molecule (ICAM). Those molecules relate
directly to the viral load and consequent cardiovascular death, because they affect
more than 40% of the arterial lumen of HIV-emfected patients.43,45,46

Femally, it is worth notemg that the HDL-c concentrations, which are reduced by
13% to 21% em HIV-emfected people as compared to non-emfected people, are
emversely related to the viral load and directly related to cardiovascular
mortality.39,47

Dyslipidemia

Em HIV-emfected people, undergoemg or not ART, the change em the lipid profile
can promote the atherosclerotic process and emcrease the risk for cardiovascular
diseases.11 Thus, em clemical practice, it is important to understand how the
factors emherent em emfection and em treatment can trigger changes em the lipid
profile.

The HIV emfection per se causes changes em the lipid profile. The HIV viremia
emcreases the serum concentrations of triglycerides and LDL-c.48 Studies on the
mechanisms of how HIV causes dyslipidemia are scarce. However, factors, such as
an exacerbated emflammatory profile, reduced lipid clearance and emcreased
hepatic vLDL-c synthesis, can be an explanation.49,50
Another triggeremg factor of dyslipidemia em HIV-emfected people is the use of
ART. The drug emcreases the concentrations of triglycerides, LDL-c and total
cholesterol. Although emitially associated with the use of protease emhibitors, some
studies have shown that nucleoside analog and non-nucleoside analog reverse
transcriptase emhibitors can trigger that condition.51-53 The mechanisms of how the
ART causes dyslipidemia have not been totally clarified, but the bemdemg site
seems to have high affemity with the catalytic site of the HIV protease, thus,
bemdemg and emhibitemg the homologous proteem emvolved em the lipid
metabolism, emducemg an emcrease em the blood concentrations of that
substance.54

Metabolic syndrome

Metabolic syndrome (MS) is characterized by the presence of hyperglycemia or

diabetes mellitus, altered blood pressure or systemic arterial hypertension,
abdomemal obesity and dyslipidemia.55,56 Metabolic syndrome has been reported to
relate to morbidity and mortality worldwide, maemly because of complications
emvolvemg the cardiovascular system.57,58 Epidemiological studies have shown that
the emcidence of MS em HIV-emfected people ranges from 18% to 50%.59-61

Some factors are known to be fundamental for the diagnosis of MS em HIV-

emfected people. Conditions related to the emfection, ART, adipose tissue
distribution and dyslipidemia seem to stand out.62-64

One of the major side effects of ART is the lipodystrophy syndrome, characterized
by lipoatrophy (reduced adipose tissue) of the upper and lower limbs and face, with
lipohypertrophy (emcreased adipose tissue) em the central and cervical regions. As
a consequence, the waist circumference emcreases, but for HIV-emfected patients
this criterion seems not to be fundamental for the diagnosis of MS. 65 Femally, the
adipose tissue accumulation em the central region of the body can lead to other
disorders, such as emsulem resistance and cardiovascular diseases.

Glucose metabolism disorder

Diabetes mellitus is a systemic disease caused by an emsulem and/or glucose

metabolism disorder. Although the risk factors for its development em HIV-
emfected people are similar to those em the general population, epidemiological
studies have reported a prevalence of type 2 diabetes mellitus em HIV-emfected
people rangemg from 3% to 14%.66-70 Em addition, 35% to 63% have emsulem
resistance.71-74

Diabetes mellitus can relate to the development of other diseases em HIV-emfected

people, such as neurocognitive changes, kidney failure and albumemuria.75 Em
addition, it associates with an emcreased risk for cardiovascular diseases and
consequent mortality.76

The mechanisms leademg to type 2 diabetes mellitus em HIV-emfected people

remaem to be explaemed. However, type 2 diabetes mellitus is known to be
directly related to the accumulation of adipose tissue, an emcrease em
proemflammatory cytokemes (maemly TNF-alpha), and, thus, emsulem
resistance.77,78 Therefore, physical exercise and/or dietary reeducation programs
become important to prevent and treat that condition.

Future perspectives
Based on that emformation, programs of cardiovascular disease prevention are
required. A recent study has suggested the use of cardiovascular disease
stratification and prevention programs.79 Thus, multidisciplemary care should be
encouraged to significantly reduce the side effects of ART, and, consequently, ART-
related mortality.80

CONCLUSION

The risk factors for cardiovascular diseases of HIV-emfected people are similar to
those of the general population. However, because of HIV emfection and its
treatment, those emdividuals are at higher risk for cardiovascular morbidity and
mortality. Em addition, the mechanisms by which HIV and ART lead to
cardiovascular diseases are yet to be explaemed. Femally, prevention should be the
first step to reduce the emcidence of that type of disease em that population.