Background: Lipid screening is recommended for patients taking protease inhibitors (PIs).
Methods: We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs).
Results: Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0–1.5), diabetic (RR = 1.2, confidence limits: 1.1–1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3–1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79–1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75–0.95).
Conclusions: Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.
Highly active antiretroviral therapy (HAART) has dramatically improved survival of HIV-infected persons since its introduction in 1995. 1 With this breakthrough, however, have come significant adverse effects of the component medications, such as hyperlipidemia.
Although other individual antiretroviral agents have been associated with dyslipidemias, all currently available protease inhibitors (PIs) have been associated with marked alterations in lipid metabolism, resulting in elevated levels of triglycerides, total cholesterol, and low-density lipoprotein (LDL). 2–7 Average total cholesterol levels increase by 30% in patients exposed to PIs, 8 and approximately 30% have total cholesterol levels >240 mg/dL. 9–12 Furthermore, a growing number of reports describe an increase in cardiovascular events in patients exposed to PIs. 13–15 Although questions remain regarding a definitive causal association with cardiovascular events, the high prevalence of hyperlipidemia is disturbing because it is a treatable and iatrogenic complication of medications that are likely to remain the mainstay of HAART for the foreseeable future. Consequently, the Department of Health and Human Services Panel on Clinical Practices for Treatment of HIV Infection continues to recommend PIs as first-line therapy for HIV infection, recommending that providers check fasting cholesterol and triglyceride levels at baseline and every 3 to 4 months thereafter, 16 echoing the recommendations of other investigators. 2,17,18
The purpose of this study is to assess the level of adherence to lipid-screening guidelines among providers caring for HIV-infected veterans exposed to PIs and to identify individual and facility-level predictors of adherence to lipid-screening guidelines.
From *Oregon Health and Sciences University, Portland, OR; †Veterans Administration (VA) Greater Los Angeles Healthcare System and VA Health Services Research & Development (HSR&D) Center of Excellence for the Study of Healthcare Provider Behavior, Los Angeles, CA; ‡Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles School of Public Health, Los Angeles, CA and §Department of Epidemiology, School of Public Health, University of California at Los Angeles School of Public Health, Los Angeles, CA; and ∥San Diego VA Medical Center and University of California at San Diego, San Diego, CA.
Received for publication June 19, 2003; accepted November 10, 2003.
Funded by the VA HSR&D Quality Enhancement Research Initiative (QUERI). P. Todd Korthuis was a VA Ambulatory Health Care Fellow (VA Office of Academic Affiliations) during the conduct of the project and received support for this project from VA HSR&D Center of Excellence for the Study of Healthcare Provider Behavior (HPF 94028), and Steven M. Asch is a recipient of the VA HSR&D Advanced Career Development Award.
Reprints: P. Todd Korthuis, Assistant Professor of Medicine, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Mail Code L-475, Portland, OR 97239–3098 (e-mail: email@example.com).