|Adverse Effects||Associated ARVs||Onset/Clinical Manifestations||Estimated Frequency||Risk Factors||Prevention/ Monitoring||Management|
↑ LDL-C, TC, and HDL-C
Reported frequency varies with specific ARV regimen, duration of ART, and the specific laboratory parameters used to diagnose lipid abnormalities.
10% to 20% of young children receiving LPV/r will have lipid abnormalities.
40% to 75% of older children and adolescents with prolonged ART history will have lipid abnormalities.
Pooled dyslipidemia prevalence of 39.5% and an incidence of 32% (191 per 1,000 person-years) reported in a recent meta-analysis and a recent review of a large consortium of prospective observational cohorts, respectively.
Advanced-stage HIV disease
High-fat, high‑cholesterol diet
Family history of dyslipidemia or premature ASCVD
Adolescents and Adults
Children (Aged ≥2 Years) without Lipid Abnormalities or Additional Risk Factors
Children with Lipid Abnormalities and/or Additional Risk Factors
Children Receiving Lipid-Lowering Therapy with Statins or Fibrates
Assess all patients for additional ASCVD risk factors. Patients with HIV are considered to be at moderate risk of ASCVD.b
ARV regimen changes should be considered, especially when the patient is receiving older PIs (e.g., LPV/r) and/or RTV boosting. Switching to a PI-sparing regimen, a PI-based regimen with a more favorable lipid profile or COBI boosting causes a decline in LDL‑C or TG values. However, the lipid-lowering effect for LDL-C is less pronounced than with statin therapy.
Refer patients to a lipid specialist early if LDL-C is ≥250 mg/dL or TG is ≥500 mg/dL.
If LDL-C is ≥130 mg/dL but <250 mg or TG is ≥150 mg/dL but <500 mg/dL, the following staged treatment approach is recommended by the NHLBI guidelines:b
The long-term risks of lipid abnormalities in children who are receiving ART are unclear. However, persistent dyslipidemia in children may lead to premature ASCVD.
|a Because of the burden of collecting fasting blood samples, some practitioners routinely measure cholesterol and TG from nonfasting blood samples and follow-up abnormal values with a test done in the fasted state.
b Refer to the NHLBI guidelines: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents (PDF).
Key: ALT = alanine aminotransferase; ART = antiretroviral therapy; ARV = antiretroviral; ASCVD = atherosclerotic cardiovascular disease; AST = aspartate aminotransferase; ATV = atazanavir; CK = creatine kinase; COBI = cobicistat; CYP3A4 = cytochrome P450 3A4; DRV = darunavir; DRV/r = darunavir/ritonavir; EFV = efavirenz; ETR = etravirine; EVG/c = elvitegravir/cobicistat; FLP = fasting lipid profile; HDL-C = high-density lipoprotein cholesterol; INSTI = integrase strand transfer inhibitor; LDLC = low-density lipoprotein cholesterol; LFT = liver function test; LPV/r = lopinavir/ritonavir; NHLBI = National Heart, Lung, and Blood Institute; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; NVP = nevirapine; OATP1B1 = organic anion transporter polypeptide 1B1; PI = protease inhibitor; PUFA = polyunsaturated fatty acid; RPV = rilpivirine; RTV = ritonavir; TAF = tenofovir alafenamide; TC = total cholesterol; TDF = tenofovir disoproxil fumarate; TG = triglycerides