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Subclinical Atherosclerosis and Markers of Immune Activation in HIV-Infected Children and Adolescents: The CaroVIH Study

Sainz, Talía MD*,†; Álvarez-Fuente, María MD; Navarro, María Luisa MD, PhD; Díaz, Laura PhD*; Rojo, Pablo MD, PhD§; Blázquez, Daniel MD§; Isabel de José, María MD, PhD; Ramos, José Tomás MD, PhD; Serrano-Villar, Sergio MD, PhD#; Martínez, Jorge MD**; Medrano, Constancio MD; Muñoz-Fernández, María Ángeles MD, PhD*; Mellado, María José MD, PhD††

JAIDS Journal of Acquired Immune Deficiency Syndromes: January 1st, 2014 - Volume 65 - Issue 1 - p 42–49
doi: 10.1097/QAI.0b013e3182a9466a
Clinical Science

Background: HIV-infected adults display increased cardiovascular disease, probably driven by inflammation and immune activation. These relationships have not been addressed in vertically HIV-infected children and adolescents, a population at very high risk for long-term non-AIDS complications.

Methods: Carotid intima media thickness (IMT) was measured in a cohort of HIV-infected children and adolescents and healthy controls. C-reactive protein and markers of immune activation (CD38+HLA-DR+) and immune senescence (CD28CD57+) were determined.

Results: One hundred fifty HIV-infected patients and 150 controls were included, 64.8% female. IMT was thicker in HIV-infected patients (0.434 mm ± 0.025 vs. 0.424 mm ± 0.018, P < 0.001). After adjustment by age, sex, body mass index, and smoking status, HIV infection was independently associated with thicker IMT (odds ratio, 2.28; 95% confidence interval: 1.25 to 4.13; P = 0.007). Among HIV-related variables, a low CD4 nadir was related to an increased IMT. Although HIV-infected subjects presented higher frequencies of activated CD4+ and CD8+ T cells (P = 0.002 and P = 0.087, respectively), no relation was found between IMT and inflammation, immune activation, or senescence.

Conclusions: Structural changes of the vasculature present early in vertically HIV-infected subjects as well as immune activation and senescence. These patients should be carefully monitored for the prompt detection and early treatment of cardiovascular disease.

*Laboratorio de InmunoBiología Molecular, Hospital General Universitario Gregorio Marañón e Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain;

Unidad de Enfermedades Infecciosas, Servicio de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain;

Unidad de Cardiología Infantil, Hospital General Universitario Gregorio Marañón, Madrid, Spain;

§Unidad de Inmunodeficiencias, Servicio de Pediatría, Hospital Universitario Doce de Octubre, Madrid, Spain;

Servicio de Pediatría, Hospital Universitario La Paz, Madrid, Spain;

Servicio de Pediatría, Hospital de Getafe, Madrid, Spain;

#Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain;

**Servicio de Pediatría, Hospital Universitario Niño Jesús, Madrid, Spain; and

††Servicio de Pediatría, Hospital Carlos III, Madrid, Spain.

Correspondence to: Talía Sainz Costa, MD, Laboratorio de Inmunobiología Molecular, Hospital Gregorio Marañón, C/Dr Esquerdo 46, 28007 Madrid, Spain (e-mail:

Partially supported by a Small Grant Award from the European Society of Pediatric Infectious Diseases and by the Spanish Ministry of Science and Innovation (FIS, grant no PI12/01483). Philips Healthcare kindly provided portable ultrasound equipment for the purpose of the study. T.S. and S.S.-V. are funded by grants from the Spanish Ministry of Science and Innovation (Ayudas para Contratos de Formación en Investigación Río Hortega). L.D. is cofunded by the Spanish Ministry of Science and Innovation. The Pediatric HIV BioBank, integrated in the Spanish AIDS Research Network, is supported by Instituto de Salud Carlos III, Spanish Health Ministry (grant no RD06/0006/0035). The Madrid Cohort of HIV-infected Children is supported by Fundación para la investigación y prevención del SIDA en España (grant no 360829-09).

The authors have no conflicts of interest to disclose.

Presented at 19th Conference on Retrovirus and Opportunistic Infections, CROI, March 5–8, 2012, Seattle, WA (ref. 971), 61st Congress of the Spanish Society of Pediatrics, AEPED, May 31–June 2, 2012, Granada, Spain (ref. C145), and 30th Congress of the European Society of Pediatric Infectious Diseases, European Society of Pediatric Infectious Diseases, May 8–12, 2012, Thessaloniky, Greece (ref. 967).

Received May 23, 2013

Accepted August 12, 2013

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Because patients treated with antiretroviral drugs live longer and have to deal with the complications of aging, much attention is turning to the so called “non-AIDS”–related pathologies; a group of conditions generally associated to aging, including cardiovascular disease (CVD), renal impairment, hepatic disease, osteoporosis, and non-AIDS–defining malignancies.1 As the mean age of HIV-infected individuals is progressively increasing, CVD is likely to gain further importance as a cause of mortality in years to come.2 Despite being the focus of intense investigation, the etiology of the increased cardiovascular risk in this population remains unclear, most probably because of a multifactorial pathophysiology.1 Indeed, it is difficult to fully isolate the weight of the different proatherogenic factors in the presence of classical CVD risk factors, which are frequently overrepresented in HIV subjects with respect to the general population. In fact, classical CVD risk factors might be overshadowing the influence of other risk factors driving atherosclerosis within HIV infection.3,4 Although this problem is of extraordinary complexity, many pathways have already been described; among them, there is mounting evidence to support that inflammation and immune activation secondary to the infection are likely to be major drivers of atherosclerosis in HIV-infected patients.5,6 In this context, the study of subclinical atherosclerosis in children and adolescents offers the opportunity to clarify the specific role of antiretroviral treatment (ART), HIV infection, inflammation, T-cell activation, and senescence on the atherogenic process in the absence of classical CVD risk factors. Previous studies have focused on this population using the intima media thickness (IMT) as a surrogate marker of CVD risk and inflammatory biomarkers such as high-sensitivity C-reactive protein (CRP) in rather small cohorts with controversial findings.7–9 Besides, it has been described that HIV-infected children present higher frequencies of activated and senescent CD8+ and CD4+ T-cell subsets,10,11 although its association to disease progression during childhood has been questioned.12 No studies to date have addressed the association between subclinical atherosclerosis and immune activation in this setting. To provide new insight into the relation between subclinical atherosis and HIV-associated variables, chronic inflammation, and immune activation, we performed a cross-sectional analysis in a large cohort of vertically HIV-infected children and adolescents and healthy controls.

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Study Design and Eligibility Criteria

We performed a cross-sectional analysis from an ongoing prospective, longitudinal, multicenter observational study evaluating cardiovascular risk in a cohort of HIV-infected children and healthy uninfected controls. Study participants are children and adolescents attending the clinics of 6 different hospitals integrated in the Madrid Cohort of Pediatric HIV-infected children and adolescents. Participants were recruited between June and December 2011. Exclusion criteria included acute or opportunistic infections, chronic inflammatory diseases, diabetes, kidney disease, hypertension, and family history of premature CVD. Healthy volunteers were prospectively enrolled as controls from healthy siblings of the HIV-infected patients, uninfected children born to HIV-infected mothers, healthy volunteers from a high school in the same urban area, and children attending the laboratory for minor surgery purposes or the general pediatric clinics. Additional exclusion criteria for healthy controls included current infectious or inflammatory illnesses, chronic conditions, and current use of medications. Controls were included with the goals of achieving a group with similar age, sex, ethnicity, and body mass index (BMI) (±1 kg/m2).

The study was reviewed and approved by the ethics committee and clinical research of the 6 participating hospitals. All participants, parents, or legal guardians and children older than 12 years gave written informed consent to take part in the study.

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Clinical Assessments

Data were collected prospectively, from an interview with the patient's family and the managing pediatrician when necessary, together with a thorough revision of medical records. All children underwent physical examination, including anthropometric and blood pressure measurement, after recommendations of the American Heart Association.13 Weight, height, BMI, and hypertension were adjusted using z score according to the age and gender.14,15 Immunovirological details and previous ART history were collected from the Cohort of Madrid collaborative Pediatric HIV Study database. Time with detectable viral load (VL) summarizes total time (years) with detectable VL during patient's life span. To study the effect of treatment, years of antiretroviral exposure have been analyzed as a continuous variable.

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Laboratory Assays

Fasting blood samples were drawn from the 150 patients and 97 controls for real-time measurements of insulin and glucose levels and lipid profile [total cholesterol, high-density lipoprotein cholesterol (HDLc), low-density lipoprotein cholesterol] that were determined in the different participating hospitals using standard enzymatic methods. Insulin resistance was calculated using the homeostasis model assessment of insulin resistance (HOMA-IR = fasting insulin (microU/mL) × fasting glucose (g/dL)/405).16

In the HIV-infected group, plasma HIV-1 VL was quantified using the Cobas TaqMan HIV-1 assay (Roche Diagnostics Systems, Inc, Branchburg, NJ) with a detection limit of 50 copies per cubic millimeter.

Absolute and percentage of CD4 and CD8 T-cell counts were concomitantly measured with standard flow cytometric methods. A sample of every participant was sent to the Pediatric HIV BioBank integrated in the Spanish AIDS Research Network (RIS) processed and stored at −80° using standard procedures for subsequent determinations.17

T-cell activation and senescence were measured by immunophenotyping performed at the Immune-Biology Laboratory of the Gregorio Marañón Hospital, from fresh samples or cryopreserved peripheral blood mononuclear cells, thawed using methods that have been optimized and validated. Peripheral blood mononuclear cells were stained using different monoclonal antibodies: CD45-RO-phycoerythrin-Cy7 (PE-Cy7) (Becton Dikinson, San Jose, CA), CD3-allophycocyanin-Cy7 (APC-Cy7), CD4-peridinin chlorophyll protein complex, CD8-PE-Cy7, CD38-PE, HLA-DR-APC, CD57-fluorescein isothiocyanate, and PD-1-PE (Beckman Coulter, Miami, FL). Cellular activation was characterized by HLA-DR+ and CD38+ expression and senescence by CD28 CD57+ expression. Stained cells were run on a Gallios flow cytometer (Beckman Coulter, Inc, Münster, Germany) and data analyzed using Kaluza software (Beckman Coulter, Inc).

High-sensitivity CRP was analyzed from frozen samples with a commercial instant ELISA kit (eBioscience, Inc, San Diego, CA), with a detection threshold of 3 pg/μL, and an intraassay and interassay coefficient of variation of 6.9% and 13.1%, respectively.

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Carotid Artery Ultrasound

IMT was examined using ultrasonography (CX50 portable equipment, Philips Medical Systems, Inc, Eindhoven, the Netherlands). Specific IMT detection software was previously calibrated using QLab (Philips Medical Systems, Inc, Eindhoven, the Netherlands).18 Measurements were made bilaterally at the common carotid artery (1–2 cm proximal to the bulb) following the Mannheim criteria.19 More than 400 measurements of a 10-mm segment of the far wall of the artery were performed and digitalized for each patient, and the median value was used for the statistical analysis as previously described.20 Images were read by an experienced cardiologist blind to the HIV status. Median value of the right and left measurement was then calculated and used for the analysis. All carotid ultrasounds were performed by 2 trained technicians who had previously participated in a pilot study (repeated and blinded measurements performed in a random sample of 36 uninfected healthy children and adolescents) that showed no evidence of systematic observer bias. The intraclass correlation coefficient was >0.90.

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Data Analyses

Qualitative variables were reported as a frequency distribution, whereas normally distributed quantitative variables were described as mean and SD. The continuous nonnormally distributed variables were reported as median and interquartile ranges (IQRs). Means for variables with a normal distribution were compared using the Student t test. Nonparametric variables were examined using the Mann–Whitney and Kruskal–Wallis tests. Given the small dispersion of the independent variable—IMT—and the absence of pediatric reference values; we classified subjects as having increased IMT when they showed a value above the healthy subjects' median (0.42 mm). Simultaneous independent associations between IMT and a subset of independent variables, including cardiovascular risk factors (sex, age, tobacco use, and BMI) and HIV seropositivity were evaluated by logistic regression analysis. Then, a second multivariate analysis was performed only in HIV-infected patients to explore the independent associations with IMT. This logistic regression model included the following variables: lipodystrophy, CD4 nadir, time with detectable VL, and cumulative exposure to ART and to protease inhibitors (PI), CD4 and CD8 T-cell count. To corroborate results, the multivariate analysis was reapplied to nonsmoker perinatally infected children. Finally, linear and logistic regression models were built to explore associations between IMT, high-sensitivity C-reactive protein (hsCRP), and the percentage of HLA-DR+ CD38+ and CD28 CD57+ T cells.

All statistical analyses were performed using the SPSS 18.0 statistical package (SPSS, Inc, Chicago, IL). The level of significance for all analyses was set at 0.05.

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Study Population and Between Group Comparison of Clinical Characteristics

The study population included 150 HIV-infected children and adolescents and 150 healthy volunteers. Main characteristics of both cohorts are summarized in Table 1. Globally, mean age was 14.8 ± 4.6 and range was 2.5–23.8. Most subjects were female (64%) and of white origin (78%). Most of HIV-infected patients (96.7%) had acquired HIV from mother-to-child transmission and all except 4 were receiving ART at the time of study evaluation. However, only 76.2% had achieved viral suppression. Median VL for the unsuppressed group was 4607 copies/mL (230–27,600) and median logVL 3.66 copies/mL (2.36–4.44). HIV infection characteristics are described in Table 1.



HIV-infected and -uninfected subjects showed similar age, gender, blood pressure, and frequency of hypertension according to z score adjusted by age and height. Although both groups had similar BMI, z score adjusted BMI was higher in the control group. On the contrary, waist-to-hip ratio was higher in the HIV-infected group. In addition, HIV-infected patients displayed significantly higher glycemia and homeostasis model assessment scores and a worse lipid profile, with decreased levels of HDLc and higher low-density lipoprotein cholesterol, total cholesterol/HDLc ratio, and triglycerides. None of the subjects had been previously diagnosed with diabetes, hypertension, or family history of premature CVD, and none was taking hypoglycemic agents, antihypertensives, statins, or fibrates. No patient was taking trimethoprim–sulfamethoxazole.

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Between Group Comparison of IMT Measurements

First of all, we compared IMT between HIV-infected and -uninfected subjects. IMT was higher in the HIV-infected children compared with the HIV-uninfected group (P < 0.001; Fig. 1A) in both unadjusted and adjusted analysis. This difference remained statistically significant when the analysis included only those patients on stable ART who had achieved undetectable VL (P < 0.001; Fig. 1B). To specifically address the effect of viral suppression, we compared IMT between virally suppressed and unsuppressed patients, and no statistically significant differences were found (P = 0.349; Fig. 1B). A multivariate analysis was built to simultaneously analyze the effect of diverse exposure variables on IMT. After adjustment by age, gender, tobacco use, BMI, non-HDL cholesterol, and triglycerides, HIV status was the only variable independently associated with higher IMT (P = 0.007; Table 2), demonstrating its independent predictive value, with a borderline significance for BMI (P = 0.057).





Subsequently, a second multivariate regression logistic analysis was performed, including only HIV-infected patients and adjusting by specific HIV-related variables. A lower CD4 nadir was the only variable associated to a higher IMT (Table 3; odds ratio (OR): 0.82 per 100 cell/mL increase; P = 0.033), with a borderline statistical significance for PI exposure (Table 3; OR: 0.89; P = 0.072). To corroborate these results, a subanalysis restricted to nonsmokers and perinatally infected children was done. Again, a lower CD4 nadir was associated to higher IMT (Table 3; OR: 0.77; P = 0.019) and PI exposure reached statistical significance (Table 3; OR: 0.84; P = 0.023). Results of both analyses are shown in Table 3.



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Between Group Comparison of High-Sensitivity CRP Measurements

CRP was determined in a representative subgroup of 64 HIV-infected patients (51 aviremic and 15 viremic) and 30 controls. No differences were found when analyzing HIV-infected subject versus HIV-uninfected controls (Table 1) or patients with detectable versus undetectable VL. No subject in the study showed markedly increased levels of CRP, suggesting acute infection. Finally, no statistical association was found between IMT measurement and CRP values (data not shown).

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Between Group Comparison of T-Cell Activation and Senescence Markers

To analyze influence of immune activation on the atherogenic process, T-cell activation and senescence markers were studied in a random subgroup of 11 controls and 38 patients (29 aviremic and 9 viremic) that underwent immunophenotyping by flow cytometry. This sample was representative of the subjects of the study (median age: 16.7 years, 66.7% women, 70.1% white, all of them vertically HIV-infected and on treatment).

Compared with uninfected subjects, HIV-infected patients had higher levels of HLA-DR+ CD38+ CD4 T cells (Fig. 2A). This difference remained significant when the comparison included only those HIV-infected patients on ART who had achieved undetectable VL (Fig. 2B). Differences in the frequency of activated CD8 T cells did not reach statistical significance (Fig. 2C). However, viremic patients showed significantly higher frequency of HLA-DR+ CD38+ CD8 T cells (Fig. 2D). The frequency of CD28 CD57+ T cells was similar between HIV-uninfected and HIV-infected subjects, both for CD4 and CD8 subsets (Figs. 2E, G). Again, viremic patients showed an increase in the percentage of CD28 CD57+ CD8 T cells (Fig. 2H).



We did not detect any significant association between markers of T-cell activation/senescence and IMT in the univariate analysis. Also, linear and logistic regression models were built to explore associations between the frequencies of activated and senescent T cells and IMT, and no association was found. Similarly, relations between both variables and hsCRP were explored, and no significant associations were detected (data not shown).

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Results of our study corroborate the hypothesis that structural changes of the arterial wall appear in the first decades of life during HIV infection, highlighting the need of a prompt diagnosis and treatment of cardiovascular risk factors during childhood. Our findings support a role for the HIV infection itself rather than for HIV-related factors or ART as suggested by other pediatric studies.7,8 Immune activation and senescence are present since childhood during HIV infection, often related to persistence of detectable VLs, although no relation to subclinical atherosclerosis was detected. To the best of our knowledge, this is the largest study analyzing factors associated with subclinical atherosclerosis in HIV-infected children and adolescents.

Although clinical manifestations of atherosclerosis do not present during childhood, the atherogenic process already begins since earliest stages of life.21 In our study, we used high-resolution ultrasound measurement of the carotid IMT to assess structural changes of the arterial wall. It is probably the most validated surrogate marker of subclinical atherosclerosis and is considered an independent predictor of adverse cardiovascular events in adults.22 Several studies have demonstrated increase of IMT in children with known cardiovascular risk factors, such as diabetes, obesity, or metabolic syndrome,23–26 and many others support the concept that anatomic changes of the arterial wall may improve over time with appropriate intervention.27–29 Different groups have evaluated atherosclerosis in HIV-infected children by means of IMT measurement.6,8,9,30–32 Most, but not all these studies showed increased IMT in HIV-infected children compared with uninfected controls, with differences in mean IMT values ranging from 0.02 to 0.15 mm. Although these rather small differences in IMT are of uncertain clinical relevance, we understand that the presence of detectable structural changes of the arterial wall in HIV-infected children is worrisome because these subjects face a long life span to develop CVD. Huge heterogeneity regarding technical aspects of IMT measurement within the studies, inclusion of rather small sample sizes, and the lack of consensus concerning characteristics of the ideal control group may explain some of these divergences among results. The only longitudinal study performed in children published to date has not been able to fully enlighten this complex question to the scientific community32. Our findings corroborate the hypothesis that structural changes of the arterial wall appear since childhood in vertically HIV-infected patients, underlining the fact that preventive measures are to be implemented in this high-risk population.

As previously mentioned, the impact of cardiovascular and HIV-related factors on CVD remains controversial as well. Although the effect of antiretroviral therapy on the vasculature has been widely studied in adult population, the existence of a correlation between cardiovascular events and ART exposure (especially PI) remains uncertain.33–35 Results of some of pediatric studies have suggested an increase of IMT associated to ART, especially PI or Stavudine exposure.6,8,31 Nevertheless, results from our study in which cumulative exposure to different antiretroviral regimens was quantified and included in the multivariate analysis, show no relation between PI or ART exposure and subclinical atherosclerosis. Moreover, PI exposure seems to be more likely a protective factor than a proatherogenic one in this large cohort of vertically HIV-infected patients. Among other HIV-related variables, CD4 T-cell count and CD4 nadir have been proposed to be the most robust risk factor for increased IMT in the adult population.36,37 Similarly, CD4 nadir has shown to be associated with thicker IMT in our study, supporting the hypothesis that immunity might play a strong role on the atherogenic process during HIV infection.

These data support the wide body of evidence suggesting that HIV itself plays a role in the development of atherosclerosis.38–41 Among underlying mechanisms, chronic inflammation and immune activation have been proposed to be at least partially responsible of the atherogenic process.6 Recent studies in adults have shown that HIV-associated T-cell changes are associated with subclinical carotid artery abnormalities; higher frequencies of activated CD4 and CD8 T cells and senescent CD8 T cells are associated with an increased prevalence of carotid artery lesions, although no relation to IMT could be demonstrated.5 To date, very few studies have focused on the effect that increased activation/senescence may have on premature clinical aging in children. In our study, higher frequencies of activated CD4 T cells were found in HIV-infected children when compared with uninfected controls. Frequencies of activated and senescent CD8 T cells were markedly increased only in those patients with detectable VL, along with findings from previous studies in children,10,11 pointing out the important effect of achieving viral suppression on the CD8 T-cell subsets. However, no relation could be established with IMT thickness. Although the minimal dispersion of IMT values in our study population may have underpowered the analyses to detect statistically significant associations with markers of T-cell activation, these findings are consistent with the recently published results from other pediatric studies, which suggest that T-cell activation is not associated to disease progression in vertically HIV-infected children.12,42 Levels of T-cell activation were rather low in our ART-treated group. A possible explanation for that finding is the fact that CMV coinfection may not be as prevalent in HIV-infected children as it is in adults. CMV seems to act synergistically to increase immune activation during HIV infection because both viruses coexist in most patients and in fact, CMV infection has been linked in HIV-infected adults to T-cell activation and atherosclerosis.43,44 Unfortunately, in our study, CMV serostatus of the participating children was not determined, and thus, effect of CMV infection could not be isolated. Whether there is a real association between HIV-induced T-cell activation and senescence and IMT remains to be answered.

To minimize the weight of classical cardiovascular risk factors, controls were enrolled aiming to achieve a group with similar age, sex, ethnicity, and BMI. However, the nature of the control group might be a limitation of the study. Uninfected ART exposed children and siblings have been proposed as the optimal control group, as socioeconomical background determines many cardiovascular risk factors. Nevertheless, it is not well known the effect that intrautero exposure to ART might have on cardiovascular parameters, and thus, recruitment of the ideal control group remains to be a challenge. In our study, no differences were found regarding absolute values of BMI between groups; however, HIV-infected children showed a statistically significant lower z score adjusted BMI. We understand that this fact could have led to underestimate the difference in IMT values between both cohorts because there is a positive correlation between IMT and BMI and provides with an additional value to the difference found.

In conclusion, we herein corroborate in a large cohort of patients that structural changes of the vasculature present early in HIV-infected subjects. CD4 nadir but not ART seems to be related to the described increased in cardiovascular risk. Most studies showing increased risk of cardiovascular events during HIV infection include adults of age around 50 years old who have been living along with the virus for a median of 3–8 years.34,45 By the time they grow that old, our vertically HIV-infected children will have been living with the infection for a period of 5–10 times longer. Thus, these patients should be carefully monitored for the prompt detection and early treatment of noninfectious disorders, and strategies are urgent to be defined for the prevention of CVD in this unique population. Long-term longitudinal follow-up of the patients included in this study is ongoing for a better understanding of the vascular changes and to ascertain the contribution of different HIV-related factors to cardiovascular risk.

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Associations between clinical factors, markers of inflammation, immune activation/senescence, and carotid IMT are analyzed in 150 HIV-infected children and 150 HIV-uninfected controls.

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The authors want to particularly acknowledge all patients and healthy volunteers and their families for their participation in this study. The authors thank all the professionals involved in the study and especially those integrating the Spanish Pediatric HIV infection Network (CORISPE) and the Pediatric HIV BioBank integrated in the Spanish AIDS Research Network (RIS). The authors would like to particularly thank S. Jimenez de Ory and J. M. Bellón for his kind help with the statistical analyses and database management.

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1. Deeks SG, Phillips AN. HIV infection, antiretroviral treatment, ageing, and non-AIDS related morbidity. BMJ. 2009;338:a3172.
2. Manfredi R. HIV infection and advanced age emerging epidemiological, clinical, and management issues. Ageing Res Rev. 2004;3:31–54.
3. Lorenz MW, Stephan C, Harmjanz A, et al.. Both long-term HIV infection and highly active antiretroviral therapy are independent risk factors for early carotid atherosclerosis. Atherosclerosis. 2008;196:720–726.
4. Currier JS, Kendall MA, Zackin R, et al.. Carotid artery intima-media thickness and HIV infection: traditional risk factors overshadow impact of protease inhibitor exposure. AIDS. 2005;19:927–933.
5. Kaplan RC, Sinclair E, Landay AL, et al.. T cell activation and senescence predict subclinical carotid artery disease in HIV-infected women. J Infect Dis. 2011;203:452–463.
6. Hsue PY, Deeks SG, Hunt PW. Immunologic basis of cardiovascular disease in HIV-infected adults. J Infect Dis. 2012;205:S375–S382.
7. Charakida M, Donald AE, Green H, et al.. Early structural and functional changes of the vasculature in HIV-infected children: impact of disease and antiretroviral therapy. Circulation. 2005;112:103–109.
8. McComsey GA, O'Riordan M, Hazen SL, et al.. Increased carotid intima media thickness and cardiac biomarkers in HIV infected children. AIDS. 2007;21:921–927.
9. Ross AC, O'Riordan MA, Storer N, et al.. Heightened inflammation is linked to carotid intima-media thickness and endothelial activation in HIV-infected children. Atherosclerosis. 2010;211:492–498.
10. Díaz L, Méndez-Lagares G, Correa-Rocha R, et al.. Detectable viral load aggravates immunosenescence features of CD8 T-cell subsets in vertically HIV-infected children. J Acquir Immune Defic Syndr. 2012;60:447–454.
11. Jin C-Z, Feng L, Xie, et al.. Expression of CD38 and HLA-DR on CD8+ T cells in pediatric AIDS patients receiving highly active antiretroviral therapy (HAART). Zhonghua Er Ke Za Zhi. 2011;49:49–52.
12. Kapetanovic S, Aaron L, Montepiedra G, et al.. T-cell activation and neurodevelopmental outcomes in perinatally HIV-infected children. AIDS. 2012;26:959–969.
13. Urbina EM, Williams RV, Alpert BS, et al.. Noninvasive assessment of subclinical atherosclerosis in children and adolescents: recommendations for standard assessment for clinical research: a scientific statement from the American Heart Association. Hypertension. 2009;54:919–950.
14. WHO. WHO Child Growth Standards: methods and development: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. Available at Accessed November 24, 2012.
15. Blood pressure tables for children and adolescents from the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents of the national Institute for Health, USA. Available at: Accessed November 31, 2012.
16. Matthews DR, Hosker JP, Rudenski AS, et al.. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985;28:412–419.
17. García-Merino I, de Las Cuevas N, Jiménez JL, et al.. Pediatric HIV BioBank: a new role of the Spanish HIV BioBank in pediatric HIV research. AIDS Res Hum Retroviruses. 2010;26:241–244.
18. Secil M, Altay C, Gulcu A, et al.. Automated measurement of intima-media thickness of carotid arteries in ultrasonography by computer software. Diagn Interv Radiol. 2005;11:105–108.
19. Touboul PJ, Hennerici MG, Meairs S, et al.. Mannheim carotid intima-media thickness consensus (2004-2006). An update on behalf of the Advisory Board of the 3rd and 4th Watching the Risk Symposium, 13th and 15th European Stroke Conferences, Mannheim, Germany, 2004, and Brussels, Belgium, 2006. Cerebrovasc Dis. 2007;23:75–80.
20. Serrano-Villar S, Estrada V, Gómez-Garre D, et al.. Incipient renal impairment as a predictor of subclinical atherosclerosis in HIV-infected patients. J Acquir Immune Defic Syndr. 2012;59:141–148.
21. Stary HC. Evolution and progression of atherosclerotic lesions in coronary arteries of children and young adults. Arteriosclerosis. 1989;9(suppl 1):I19–I32.
22. Lorenz MW, Markus HS, Bots ML, et al.. Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation. 2007;115:459–467.
23. Järvisalo MJ, Jartti L, Näntö-Salonen K, et al.. Increased aortic intima-media thickness: a marker of preclinical atherosclerosis in high-risk children. Circulation. 2001;104:2943–2947.
24. Järvisalo MJ, Raitakari M, Toikka JO, et al.. Endothelial dysfunction and increased arterial intima-media thickness in children with type 1 diabetes. Circulation. 2004;109:1750–1755.
25. Lamotte C, Iliescu C, Libersa C, et al.. Increased intima-media thickness of the carotid artery in childhood: a systematic review of observational studies. Eur J Pediatr. 2011;170:719–729.
26. Reinehr T, Wunsch R. Intima media thickness-related risk factors in childhood obesity. Int J Pediatr Obes. 2011;6(suppl1):46–52.
27. Farpour-Lambert NJ, Aggoun Y, Marchand LM, et al.. Physical activity reduces systemic blood pressure and improves early markers of atherosclerosis in pre-pubertal obese children. J Am Coll Cardiol. 2009;54:2396–2406.
28. Lass N, Kleber M, Winkel K, et al.. Effect of lifestyle intervention on features of polycystic ovarian syndrome, metabolic syndrome, and intima-media thickness in obese adolescent girls. J Clin Endocrinol Metab. 2011;96:3533–3540.
29. Woo KS, Chook P, Yu CW, et al.. Effects of diet and exercise on obesity-related vascular dysfunction in hildren. Circulation. 2004;109:1981–1986.
30. Bonnet D, Aggoun Y, Szezepanski I, et al.. Arterial stiffness and endothelial dysfunction in HIV-infected children. AIDS. 2004;18:1037–1041.
31. Giuliano IC, de Freitas SF, de Souza M, et al.. Subclinic atherosclerosis and cardiovascular risk factors in HIV-infected children: PERI study. Coron Artery Dis. 2008;19:167–172.
32. Ross AC, Storer N, O'Riordan MA, et al.. Longitudinal changes in carotid intima-media thickness and cardiovascular risk factors in human immunodeficiency virus-infected children and young adults compared with healthy controls. Pediatr Infect Dis J. 2010;29:634–638.
33. Carr A, Cooper DA. Adverse effects of antiretroviral therapy. Lancet. 2000;356:1423–1430.
34. Friis-Møller N, Sabin CA, Weber R, et al.. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med. 2003;349:1993–2003.
35. Hulten E, Mitchell J, Scally J, et al.. HIV positivity, protease inhibitor exposure and subclinical atherosclerosis: a systematic review and meta-analysis of observational studies. Heart. 2009;95:1826–1835.
36. Kaplan RC, Kingsley LA, Gange SJ, et al.. Low CD4+ T-cell count as a major atherosclerosis risk factor in HIV-infected women and men. AIDS. 2008;22:1615–1624.
37. Hsue PY, Lo JC, Franklin A, et al.. Progression of atherosclerosis as assessed by carotid intima-media thickness in patients with HIV infection. Circulation. 2004;109:1603–1608.
38. Arese M, Ferrandi C, Primo L, et al.. HIV-1 Tat protein stimulates in vivo vascular permeability and lymphomononuclear cell recruitment. J Immunol. 2001;166:1380–1388.
39. Eugenin EA, Morgello S, Klotman ME, et al.. Human immunodeficiency virus (HIV) infects human arterial smooth muscle cells in vivo and in vitro: implications for the pathogenesis of HIV-mediated vascular disease. Am J Pathol. 2008;172:1100–1111.
40. Oliviero U, Bonadies G, Apuzzi V, et al.. Human immunodeficiency virus per se exerts atherogenic effects. Atherosclerosis. 2008;204:586–589.
41. Park IW, Wang JF, Groopman JE. HIV-1 Tat promotes monocyte chemoattractant protein-1 secretion followed by transmigration of monocytes. Blood. 2001;97:352–358.
42. Romeiro JR, Pinto JA, Silva ML, et al.. Further evidence that the expression of CD38 and HLA-DR+ in CD8+ Lymphocytes Does not Correlate to disease progression in HIV-1 vertically infected children. J Int Assoc Physicians AIDS Care. 2002;11:164–168.
43. Sacre K, Hunt PW, Hsue P, et al.. A role for cytomegalovirus-specific CD4+CX3CR1+ T cells and cytomegalovirus-induced T-cell immunopathology in HIV-associated atherosclerosis. AIDS. 2012;26:805–814.
44. Hsue P, Hunt PW, Sinclair E, et al.. Increased carotid intima-media thickness in HIV patients is associated with increased cytomegalovirus-specific T-cell responses. AIDS. 2006;20:2275–2283.
45. El-Sadr WM, Lundgren J, Neaton JD, et al.. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 2006;355:2283–2296.

HIV; adolescents; cardiovascular risk factors; IMT; immune activation

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