Research

Brief Report

Effects of Antiretroviral Therapy on Immune Function

and Arterial Inflammation in Treatment-Naive Patients
With Human Immunodeficiency Virus Infection
Markella V. Zanni, MD; Mabel Toribio, MD; Gregory K. Robbins, MD; Tricia H. Burdo, PhD; Michael T. Lu, MD; Amorina E. Ishai, MD;
Meghan N. Feldpausch, NP; Amanda Martin, AB; Kathy Melbourne, PharmD; Virginia A. Triant, MD, MPH; Sujit Suchindran, MD;
Hang Lee, PhD; Udo Hoffmann, MD, MPH; Kenneth C. Williams, PhD; Ahmed Tawakol, MD; Steven K. Grinspoon, MD

Invited Commentary page 481

IMPORTANCE Individuals with human immunodeficiency virus (HIV) infection receiving Supplemental content at
combined antiretroviral therapy (ART) have an increased risk of myocardial infarction. Effects jamacardiology.com
of ART on arterial inflammation among treatment-naive individuals with HIV are unknown.

OBJECTIVE To determine the effects of newly initiated ART on arterial inflammation and
other immune/inflammatory indices in ART-naive patients with HIV infection.

DESIGN, SETTING, PARTICIPANTS Twelve treatment-naive HIV-infected individuals underwent

fludeoxyglucose F 18 ([18F]-FDG) positron emission tomographic scanning for assessment of
arterial inflammation, coronary computed tomographic angiography for assessment of
subclinical atherosclerosis, and systemic immune and metabolic phenotyping before and 6
months after the initiation of therapy with elvitegravir, cobicistat, emtricitabine, and
tenofovir disoproxil fumarate (combined ART). Systemic immune and metabolic factors were
also assessed in 12 prospectively recruited individuals without HIV serving as controls. The
study began July 24, 2012, and was completed May 7, 2015.

INTERVENTIONS Combined ART in the HIV-infected cohort.

MAIN OUTCOMES AND MEASURES The primary outcome was change in aortic target-background
ratio (TBR) on [18F]-FDG-PET with combined ART in the HIV-infected group.

RESULTS For the 12 participants with HIV infection (mean (SD) age, 35 [11] years), combined
ART suppressed viral load (mean [SD] log viral load, from 4.3 [0.6] to 1.3 [0] copies/mL;
P < .001), increased the CD4+ T-cell count (median [IQR], from 461 [332-663] to 687
[533-882] cells/mm3; P < .001), and markedly reduced percentages of circulating activated
CD4+ T cells (human leukocyte antigen-D related [HLA-DR]+CD38+CD4+) (from 3.7 [1.8-5.0]
to 1.3 [0.3-2.0]; P = .008) and CD8+ T cells (HLA-DR+CD38+CD8+) (from 18.3 [8.1-27.0] to 4.0
[1.5-7.8]; P = .008), increased the percentage of circulating classical CD14+CD16− monocytes
(from 85.8 [83.7-90.8] to 91.8 [87.5-93.2]; P = .04), and reduced levels of CXCL10 (mean
[SD] log CXCL10, from 2.4 [0.4] to 2.2 [0.4] pg/mL; P = .03). With combined ART, uptake of
[18F]-FDG in the axillary lymph nodes, as measured by TBR, decreased from a median (IQR) of
3.7 (1.3-7.0) at baseline to 1.4 (0.9-1.9; P = .01) at study end. In contrast, no significant
decrease was seen in aortic TBR in response to combined ART (mean [SD], 1.9 [0.2]; median
[IQR], 2.0 [1.8-2.1] at baseline to 2.2 [0.4]; 2.1 [1.9-2.6], respectively, at study end; P = .04 by
2-way test, P = .98 for test of decrease by 1-way test). Changes in aortic TBR during combined
ART were significantly associated with changes in lipoprotein-associated phospholipase A2
(n = 10; r = 0.67; P = .03). Coronary plaque increased among 3 participants with HIV infection Author Affiliations: Author
with baseline plaque and developed de novo in 1 participant during combined ART. affiliations are listed at the end of this
article.
CONCLUSIONS AND RELEVANCE Newly initiated combined ART in treatment-naive individuals Corresponding Author: Steven K.
Grinspoon, MD, Program in
with HIV infection had discordant effects to restore immune function without reducing
Nutritional Metabolism,
arterial inflammation. Complementary strategies to reduce arterial inflammation among Massachusetts General Hospital
ART-treated HIV-infected individuals may be needed. and Harvard Medical School,
55 Fruit St, 5 Longfellow Pl,
JAMA Cardiol. 2016;1(4):474-480. doi:10.1001/jamacardio.2016.0846 Room 207, Boston, MA 02114
Published online May 25, 2016. (sgrinspoon@partners.org).

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 Antiretroviral Therapy Effects on Immune Function and CVD Risk in HIV Infection
M
yocardial infarction rates are increased by 50% in in-
dividuals with human immunodeficiency virus (HIV)
infection compared with uninfected persons, con-
trolling for traditional cardiovascular disease (CVD) risk
factors.1,2 Mechanisms for increased risk of myocardial infarc-
tion in HIV infection remain unclear but may relate in part to
the effects of the virus itself and the body’s immune
response.3,4 Effects of antiretroviral therapy (ART) on myo-
cardial infarction risk in HIV are not fully understood.5,6
We explored the effects of newly initiated integrase-
inhibitor–based ART on arterial inflammation by fludeoxyglu-
cose F 18 ([18F]-FDG) positron emission tomography (PET)
among treatment-naive patients with HIV infection without
known CVD. Arterial inflammation is a marker of CVD risk in
the general population7 and is increased among individuals
with HIV infection who receive ART.8 We hypothesized that
initiation of ART in treatment-naive persons would reduce ar-
terial inflammation as well as systemic immune activation/
inflammation.
Methods
Study Design
This study9 evaluated the effects of initiation of ART with el-
vitegravir, cobicistat, emtricitabine, and tenofovir disoproxil
fumarate (hereinafter, combined ART) on arterial inflamma-
tion by cardiac [18F]-FDG-PET scanning among ART-naive in-
dividuals with HIV infection. The effects of combined ART on
coronary plaque observed on coronary computed tomo-
graphic angiography (CCTA) and systemic immune and meta-
bolic factors were simultaneously assessed. The study began
July 24, 2012, and was completed May 7, 2015. All partici-
pants provided written informed consent and received finan-
cial compensation. The study was approved by the Massachu-
setts General Hospital institutional review board.
Twelve ART-naive men with HIV infection initiating com-
bined ART once daily by their treating physician were re-
cruited from infectious disease clinics in Boston. All 12 par-
ticipants qualified and enrolled at the General Clinical Research
Center at Massachusetts General Hospital. In addition, 12 con-
firmed HIV-negative individuals were recruited for contextu-
alization of data on immune and inflammatory indices in the
HIV-infected group (eFigure 1 in the Supplement). Unin-
fected control participants underwent blood testing only at
baseline and did not receive combined ART or undergo [18F]-
FDG-PET or CCTA. Participants in both the treatment and
control groups were enrolled based on similar criteria,
including age older than 18 years, no current or prior coro-
nary artery disease or significant autoimmune or inflamma-
tory disease, and estimated glomerular filtration rate of 70
mL/min/1.73 m 2 or more. For HIV-infected participants,
assessments were performed at baseline and after 6 months
of combined ART. Assessments were delayed beyond 6
months in 3 of 12 participants, 1 of whom did not undergo
end-of-study [18F]-FDG-PET. The median (interquartile range
[IQR]) time of follow-up, including these 3 individuals, was
6.4 (6.0-7.4) months.
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Brief Report Research
Key Points
Question Does the initiation of effective antiretroviral therapy
(ART) in antiretroviral-naive human immunodeficiency virus
(HIV)–infected patients reduce arterial inflammation as assessed
by fludeoxyglucose F 18 positron emission tomography?
Findings In this study of ART initiation in ART-naive patients with
HIV, initiation of a contemporary regimen (elvitegravir, cobicistat,
emtricitabine, and tenofovir disoproxil fumarate) improved
systemic immune factors, whereas arterial inflammation was not
reduced after 6 months of treatment.
Meaning Newly initiated ART may not be sufficient to reduce
arterial inflammation, and complementary strategies to ART may
be needed to further improve immune activation and reduce
arterial inflammation in HIV-infected patients.
Study Procedures
Individuals with HIV infection underwent [18F]-FDG-PET
scanning8 of the aorta, heart, axillary lymph nodes, spleen,
and bone marrow. These patients also underwent CCTA10
(eMethods in the Supplement). Lipid and creatinine levels
were determined using standard techniques. The CD4+ and
CD8+ T-cell counts were determined using flow cytometry.
The HIV viral load was determined using ultrasensitive
reverse transcriptase polymerase chain reaction with a lower
limit of detection of 20 copies/mL (Cobas AmpliPrep; Roche
Molecular Diagnostics). Flow cytometric analysis of lympho-
cytes and monocytes was performed, and levels of immune
and inflammatory biomarkers were assessed (eMethods in
the Supplement).
Statistical Analysis
The prespecified primary end point was change in aortic target-
background ratio (TBR) on [18F]-FDG-PET with combined ART
in the HIV-infected group. The study was powered at 80% to
detect a decrease in aortic TBR of 0.3 (1-way testing) based on
an assumed SD of 0.42.8 The study size was chosen a priori to
enable detection of a decrease in aortic TBR of 0.3, represent-
ing the difference between (ART-treated) HIV-infected and un-
infected groups in prior work.8 The selected 6-month study
duration was long enough to allow for combined ART effects
on arterial and systemic inflammation. Other anti-inflam-
matory strategies have reduced aortic TBR in comparable time
frames.11 Two-way tests for change within the HIV group are
reported for all variables. A 1-way test for change is also re-
ported for aortic TBR, the primary end point, consistent with
the primary study hypothesis. Matched-pairs testing was used
to assess change in variables in response to combined ART
among ART-naive individuals with HIV infection. A t test was
used for log-transformed data; otherwise, Wilcoxon signed rank
tests were used. Between-group comparisons of data for the
HIV-infection vs noninfection groups were made using a t test
for log-transformed data, the Wilcoxon rank sum test as ap-
propriate for continuous data, and the χ2 test for categorical
data. P < .05 indicates statistical significance. Statistical analy-
ses were performed using SAS JMP software, version 11.0 (SAS
Institute Inc).
(Reprinted) JAMA Cardiology July 2016 Volume 1, Number 4 475
 Research Brief Report
Results
Baseline Immune and Cardiometabolic Parameters
Participants with HIV infection were ART-naive, with a
median (IQR) time since diagnosis of 0.9 (0.2-1.7) years,
mean (SD) CD4+ count of 483 (166) cells/mm3, and viral load
of 4.3 (0.6) log copies. Mean (SD) age was 35 (11) years. The
HIV-infected and uninfected groups had very low and simi-
lar traditional CVD risk scores (10-year atherosclerotic car-
diovascular disease risk score, 2.1% vs 1.8%; P = .91) (eTable 1
in the Supplement). No participants were receiving statin
therapy. At baseline, before ART, HIV-infected individuals
demonstrated a higher percentage of activated CD4+ and
CD8+ T cells and higher levels of the chemokine CXCL10
compared with controls (Table).
Effects of Combined ART
Arterial Inflammation and Coronary Plaque
In response to combined ART, aortic TBR increased from a
baseline mean (SD) of 1.9 (0.2) (median [IQR], 2.0 [1.8-2.1])
to 2.2 (0.4) (2.1 [1.9-2.6]) (P = .04 using a 2-way test; P = .98
using a 1-way test for decrease) (Figure 1, Figure 2, and
Table). A strong association was observed between the
increase in aortic TBR and increase in lipoprotein-associated
phospholipase A2 (n = 10; r = 0.67; P = .03). At baseline, 3 of
12 patients (25%) with HIV infection demonstrated subclini-
cal coronary plaque. In addition, 1 HIV-infected participant
without baseline plaque developed de novo plaque during
the study period. Total, noncalcified, and calcified plaque
volumes were higher after therapy among participants with
HIV infection who had any plaque at baseline (eTable 2 in
the Supplement).
Inflammation in Axillary Lymph Nodes, Spleen, and Bone Marrow
Among participants with HIV infection, there was visible high-
level [18F]-FDG uptake in the bilateral axillary lymph nodes,
spleen, and bone marrow. In response to combined ART, the
bilateral axillary lymph node TBR was reduced significantly
(Figure 1, Figure 2, and Table). There was also a trend toward
a reduction in TBR in the spleen but not in the bone marrow
(Table).
Immune Function and Systemic Markers of Immune Activation
Treatment with combined ART increased the CD4+ count
and CD4/CD8 ratio and reduced the viral load (P < .001) as
anticipated (Table and eFigure 2 in the Supplement). Viral
load, assessed by an ultrasensitive assay, was suppressed to
undetectable levels (<20 copies/mL) in 11 of 12 participants
and to 25 copies/mL in 1 individual. Combined ART also
reduced the percentage of circulating activated CD4+ and
CD8+ T cells as well as the levels of the chemokine CXCL10,
albeit not to the levels observed in the control group (Table
and eFigure 3 in the Supplement). Finally, combined ART
increased the circulating percentage of classical CD14+CD16−
monocytes with a trend toward a concomitant decrease in
the percentage of CD14+CD16+ monocytes (Table and eFigure
3 in the Supplement).
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Antiretroviral Therapy Effects on Immune Function and CVD Risk in HIV Infection
Metabolic and Renal Indices
With combined ART, high-density lipoprotein cholesterol
levels tended to increase and total cholesterol levels
increased modestly, but the ratio of total cholesterol to
high-density lipoprotein cholesterol did not change. Creati-
nine levels increased slightly. There was no association
between change in metabolic and renal function values and
change in aortic TBR. Overall, the 10-year atherosclerotic
cardiovascular disease risk score did not change signifi-
cantly (Table).
Adverse Events
Combined ART was well tolerated. No serious adverse events
related to combined ART were reported.
Discussion
Arterial inflammation, reflected in the aortic TBR, did not de-
crease after treatment with combined ART. In contrast, the TBR
of the axillary lymph nodes consistently decreased with com-
bined ART. For context, the increase in aortic TBR among par-
ticipants initiating combined ART in the present study re-
sulted in a final level of aortic TBR approximately equivalent
to that seen among HIV-infected patients receiving long-
term ART in a prior study.8 We observed a significant correla-
tion between ART-induced changes in 2 separate measures of
arterial inflammation–aortic TBR on [18F]-FDG PET and plasma
levels of lipoprotein-associated phospholipase A2, a marker that
relates to incident CVD events in the general population.12 Al-
though our study was not primarily powered to detect changes
in coronary plaque, our CCTA assessments revealed progres-
sion of atherosclerotic plaque volume coinciding with ART
treatment among individuals with HIV infection who had
plaque. Changes in coronary plaque volume occurred over a
short time period among young patients with HIV infection
who had a low 10-year atherosclerotic cardiovascular disease
risk score.
Changes in arterial inflammation and coronary athero-
sclerosis with combined ART occurred in the context of
improved immune homeostasis. In addition to potently sup-
pressing viremia, combined ART increased the CD4+ T-cell
count and reduced axillary lymph node TBR on [18F]-FDG-
PET. Combined ART also reduced CD4+ and CD8+ T-cell acti-
vation and levels of the chemoxine CXCL10, although not to
the levels seen in the controls. Moreover, with therapy, sub-
populations of circulating monocytes shifted, favoring a
relative increase in the percentage of classical CD14+CD16−
monocytes and a decrease in the intermediate/inflammatory
CD14+CD16+ population. For context, previous studies13 have
demonstrated effects of select ART regimens, including
those incorporating the integrase inhibitor raltegravir, to
reduce CD4+ and CD8+ T-cell activation. In previous studies
involving other regimens, newly initiated ART did not
change the proportions of monocyte subsets but did change
patterns of monocyte cell-surface expression.14
Several possible explanations exist for why arterial inflam-
mation was not reduced in the context of favorable combined
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 Antiretroviral Therapy Effects on Immune Function and CVD Risk in HIV Infection Brief Report Research

Table. Effects of Newly Initiated Combined ARTa

HIV+ Group P Value

HIV+ at HIV+ After
P Value Change Baseline Treatment
Characteristic At Baseline After Treatment Over Time Control Groupb vs Control vs Control
Traditional Risk Factors
TC, mean (SD), mg/dL 155 (29) (n = 12) 173 (35) (n = 12) 175 (32) (n = 12)
Median (IQR) 159 (136-172) 163 (147-194) .01 (n = 12) 173 (153-186) .09 .73
LDL-C, mean (SD), mg/dL 93 (26) (n = 12) 101 (32) (n = 12) 102 (24) (n = 12)
Median (IQR) 99 (68-101) 94 (74-123) .15 (n = 12) 108 (76-114) .18 .58
HDL-C, mean (SD), mg/dL 45 (14) (n = 12) 49 (10) (n = 12) 55 (16) (n = 12)
Median (IQR) 40 (36-47) 45 (41-56) .06 (n = 12) 52 (45-64) .06 .27
TC-to-HDL-C ratio, mean (SD) 3.7 (0.9) (n = 12) 3.7 (0.8) (n = 12) 3.3 (0.7) (n = 12)
Median (IQR) 3.5 (3.0-4.4) 3.6 (3.3-4.1) .79 (n = 12) 3.3 (2.6-4.0) .40 .44
Triglycerides, mean (SD), 89 (29) (n = 12) 119 (69) (n = 12) 89 (34) (n = 12)
mg/dL
Median (IQR) 90 (60-116) 92 (80-163) .12 (n = 12) 96 (58-113) .93 .58
Systolic BP, mean (SD), mm Hg 116 (7) (n = 12) 118 (8) (n = 12) 123 (14) (n = 12)
Median (IQR) 115 (112-121) 118 (111-120) .33 (n = 12) 119 (112-139) .22 .43
BMI, mean (SD) 25.7 (3.6) (n = 12) 26.0 (3.4) (n = 12) 26.2 (2.9) (n = 12)
Median (IQR) 25.8 (22.6-28.1) 25.9 (23.4-27.1) .30 (n = 12) 25.3 (24.3-28.9) .84 .80
WHR, mean (SD), iliac waist 0.9 (0.1) (n = 12) 0.9 (0.1) (n = 12) 0.9 (0.1) (n = 12)
Median (IQR) 0.9 (0.8-0.9) 0.9 (0.9-1.0) .02 (n = 12) 1.0 (0.9-1.0) .18 .35
10-y ASCVD risk score (%), 2.5 (1.8) (n = 12) 2.7 (2.0) (n = 12) 4.2 (6.6) (n = 12)
mean (SD)c
Median (IQR) 2.1 (0.7-3.6) 2.1 (0.8-4.9) .28 (n = 12) 1.8 (0.7-5.3) .91 >.99
Creatinine, mean (SD), mg/dL 0.89 (0.16) (n = 12) 0.96 (0.17) (n = 12)
Median (IQR) 0.90 (0.76-0.99) 0.96 (0.82-1.08) .02 (n = 12)
HIV-Specific Factors
CD4+ T-cell count, mean (SD), 483 (166) (n = 12) 698 (197) (n = 12)
cells/mm3
Median (IQR) 461 (332-663) 687 (533-882) <.001 (n = 12)
+
CD8 T-cell count, mean (SD), 933 (576) (n = 12) 922 (435) (n = 12)
cells/mm3
Median (IQR) 767 (594-1009) 723 (602-1321) >.99 (n = 12)
CD4/CD8 ratio, mean (SD) 0.63 (0.28) (n = 12) 0.89 (0.40) (n = 12)
Median (IQR) 0.60 (0.42-0.80) 0.87 (0.54-1.25) <.001 (n = 12)
Log VL, mean (SD), copies/mL 4.3 (0.6) (n = 12) 1.3 (0) (n = 12) <.001 (n = 12)
Median (IQR) 4.5 (3.9-4.8) 1.3 (1.3-1.3)
Immune Activation and Inflammation Factorsd
Log soluble CD163, mean (SD), 3.1 (0.2) (n = 12) 3.2 (0.2) (n = 12) .58 (n = 12) 3.0 (0.2) (n = 12) .12 .06
ng/mL
Median (IQR) 1253 (910-1779) 1521 (1088-2318) 956 (608-1281)
Log soluble CD14, mean (SD), 3.4 (0.1) (n = 12) 3.2 (0.4) (n = 12) .08 (n = 12) 3.3 (0.3) (n = 12) .10 .53
ng/mL
Median (IQR) 2819 (2209-3012) 2447 (582-2764) 2082 (1697-2832)
Log CXCL10, mean (SD), pg/mL 2.4 (0.4) (n = 12) 2.2 (0.4) (n = 12) .03 (n = 12) 1.9 (0.2) (n = 12) .001 .03
Median (IQR) 234 (132-599) 144 (93-293) 78 (59-112)
Log Lp-PLA2, mean (SD), ng/mL 2.2 (0.1) (n = 12) 2.3 (0.1) (n = 12) .07 (n = 12) 2.3 (0.1) (n = 12) .03 .60
Median (IQR) 158 (142-219) 192 (156-234) 203 (198-216)
Log MCP-1, mean (SD), pg/mL 2.2 (0.1) (n = 12) 2.2 (0.1) (n = 12) .93 (n = 12) 2.2 (0.1) (n = 12) .72 .79
Median (IQR) 162.5 (126.4-192.8) 143.7 (131.3-188.7) 153.9 (131.1-198.8)
Log hsIL-6, mean (SD), pg/mL 0.2 (0.2) (n = 12) 0.2 (0.4) (n = 12) .82 (n = 12) 0.2 (0.2) (n = 12) .99 .84
Median (IQR) 1.5 (0.9-2.2) 1.3 (0.9-1.5) 1.3 (0.9-2.1)
Log CRP, mean (SD), ng/mL 2.2 (0.7) (n = 12) 2.1 (0.4) (n = 12) .63 (n = 12) 2.2 (0.6) (n = 12) .73 .45
Median (IQR) 83 (43-365) 132 (69-265) 147 (86-369)

(continued)

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 Research Brief Report Antiretroviral Therapy Effects on Immune Function and CVD Risk in HIV Infection

Table. Effects of Newly Initiated Combined ARTa (continued)

HIV+ Group P Value

HIV+ at HIV+ After
P Value Change Baseline Treatment
Characteristic At Baseline After Treatment Over Time Control Groupb vs Control vs Control
Flow Cytometry Factors
% CD4+ T cells, mean (SD), as % 24.3 (13.7) (n = 10) 26.4 (17.8) (n = 10) 42.6 (13.8) (n = 12)
of lymphocytes
Median (IQR) 30.1 (15.3-32.3) 32.2 (4.2-38.5) .15 (n = 8) 45.7 (39.3-50.5) .002 .009
% HLA-DR+CD38+CD4+ T cells, 4.7 (5.0) (n = 10) 1.4 (1.2) (n = 10) 0.3 (0.2) (n = 12)
mean (SD), as % of CD4+ T cells
Median (IQR) 3.7 (1.8-5.0) 1.3 (0.3-2.0) .008 (n = 8) 0.3 (0.1-0.4) <.001 .02
% CD8+ T cells, mean (SD), as % 44.6 (10.7) (n = 10) 40.1 (9.0) (n = 10) 24.4 (8.7) (n = 12)
of lymphocytes
Median (IQR) 40.7 (35.5-53.6) 38.4 (32.8-49.8) .02 (n = 8) 24.6 (18.0-28.8) <.001 .001
% HLA-DR+CD38+CD8+ T cells, 17.4 (9.9) (n = 10) 5.5 (5.1) (n = 10) 1.8 (1.6) (n = 12)
mean (SD), as % of CD8+ T cells
Median (IQR) 18.3 (8.1-27.0) 4.0 (1.5-7.8) .008 (n = 8) 1.3 (0.6-3.1) <.001 .02
% CD14−CD16+, mean (SD), 5.2 (3.2) (n = 10) 3.7 (1.8) (n = 11) 3.5 (1.2) (n = 12)
as % of monocytes
Median (IQR) 4.7 (2.8-7.2) 3.1 (2.1-5.1) .20 (n = 9) 3.2 (2.6-3.7) .14 .93
% CD14+CD16+, mean (SD), 10.2 (9.6) (n = 10) 5.2 (2.5) (n = 11) 9.8 (5.3) (n = 12)
as % of monocytes
Median (IQR) 8.0 (3.7-11.6) 4.4 (3.0-7.4) .07 (n = 9) 8.7 (6.7-12.2) .60 .01
% CD14+CD16−, mean (SD), 83.8 (12.2) (n = 10) 90.8 (2.9) (n = 11) 85.8 (6.4) (n = 12)
as % of monocytes
Median (IQR) 85.8 (83.7-90.8) 91.8 (87.5-93.2) .04 (n = 9) 88.0 (85.2-89.7) .72 .03
[18F]-FDG-PET Factors
Aortic TBR, mean (SD) 1.9 (0.2) (n = 11) 2.2 (0.4) (n = 10)
Median (IQR) 2.0 (1.8-2.1) 2.1 (1.9-2.6) .04 (n = 10)
Splenic TBR, mean (SD) 3.3 (0.8) (n = 12) 2.9 (0.7) (n = 11)
Median (IQR) 3.4 (2.8-3.7) 2.8 (2.5-3.3) .15 (n = 11)
Bone marrow TBR, mean (SD) 3.2 (0.5) (n = 12) 3.2 (0.6) (n = 11)
Median (IQR) 3.2 (3.0-3.5) 3.0 (2.7-3.7) .58 (n = 11)
Bilateral axillary lymph node TBR, 4.5 (4.1) (n = 12) 1.5 (1.0) (n = 11)
mean (SD)
Median (IQR) 3.7 (1.3-7.0) 1.4 (0.9-1.9) .01 (n = 11)
Abbreviations: ASCVD, atherosclerotic cardiovascular disease; BMI, body mass elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate
index (calculated as weight in kilograms divided by height in meters squared); (combined ART) among ART-naive individuals with HIV infection; t test was
BP, blood pressure; CRP, C-reactive protein; [18F]-FDG-PET, fludeoxyglucose F used for log-transformed data; otherwise, Wilcoxon signed rank tests were
18 positron emission tomography; HDL-C, high-density lipoprotein cholesterol; used. Between-group comparisons of data for the HIV-infection vs
HIV, human immunodeficiency virus; HLA-DR, human leukocyte antigen D noninfection groups were made using t test for log-transformed data, and
related; hs, high sensitivity; IQR, interquartile range; LDL-C, low-density otherwise using the Wilcoxon rank sum test as appropriate, for continuous
lipoprotein cholesterol; LP-PLA2, lipoprotein-associated phospholipase A2; data and using the χ2 test for categorical data. P < .05 indicates statistical
MCP-1, monocyte chemoattractant protein-1; TBR, target-background ratio; TC, significance.
total cholesterol; VL, viral load; WHR, waist-hip ratio. b
Empty cells indicate that testing was not conducted.
SI conversion factors: To convert creatinine to micromoles per liter, multiply by c
For participants outside the 40- to 75-year age range, an imputed age was
88.4; HDL-C, LDL-C, and TC to millimoles per liter, multiply by 0.0259; and used to calculate the 10-year ASCVD Risk Score.
triglycerides to micromoles per liter, multiply by 0.0113. d
The median (IQR) values refer to the non–log-transformed data.
a
Matched-pairs testing was used to assess change in variables in response to

ART effects on immune factors. First, combined ART only par-
tially dampened select indices of immune activation. For ex-
ample, although combined ART reduced T-cell activation, the
percentage of circulating activated T cells remained elevated
compared with those seen in the control participants. In addi-
tion, select monocyte activation markers linked to arterial
inflammation8 were not reduced by combined ART therapy.
Second, effects of integrase inhibitor–based therapy to alter
monocyte cell surface receptor expression (eg, expression of
CX3CR1, not tested in this study) could influence honing of
monocytes to the vascular endothelium.15 Third, small, antici-
pated combined ART-mediated effects to increase creatinine
levels16 might be expected to influence arterial inflammation,
but in our study, change in creatinine levels did not relate to
change in aortic TBR. Finally, it is possible that different re-
sults would be observed among patients with a longer dura-
tion of HIV infection, longer duration of ART, or higher base-
line traditional CVD risk.
Our findings reinforce the overall benefits of immediate
ART,17 including favorable effects of ART to suppress viremia,

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 Antiretroviral Therapy Effects on Immune Function and CVD Risk in HIV Infection Brief Report Research

Figure 1. Representative Fludeoxyglucose F 18 Positron Emission
Tomographic Imaging of the Aorta and Axillary Lymph Nodes (Ax LNs)
A HIV+ at baseline
Figure 2. Effects of Combination Antiretroviral Therapy (ART)
on Fludeoxyglucose F 18 Positron Emission Tomography ([18F]-FDG-PET)
Parameters
A Overall treatment group

18 P =.01 3.5
P =.04

Bilateral Axillary Lymph Node TBR

16
Right 14 3.0
Left
Ax LN Ax LN 12

Aortic TBR
2.5
Aorta 10
8
2.0
6
4 1.5
2

B HIV+ after treatment 0 1.0

Baseline After Baseline After
Treatment Treatment

B Individual results
18 P =.01 3.5
Right Left P =.04

Bilateral Axillary Lymph Node TBR

Ax LN Ax LN 16
Aorta 14 3.0

12

Aortic TBR
2.5
10
8
2.0
6
Increased aortic target-background ratio shown in a treatment-naive patient 4 1.5
with human immunodeficiency virus infection before (A) and after (B)
2
antiretroviral therapy using elvitegravir, cobicistat, emtricitabine, and tenofovir
disoproxil fumarate. In contrast, lymph node target-background ratio decreased 0 1.0
Baseline After Baseline After
with combined ART in the same individual. Treatment Treatment

partially restore immune homeostasis, and partially dampen
select immune activation indices. However, our longitudinal
study provides novel data derived from [18F]-FDG-PET and
CCTA to suggest for what we believe to be the first time that
these effects may be insufficient to forestall the progression of
HIV-associated CVD, at least over the short-term. Comple-
mentary strategies to further improve immune activation
indices and arterial inflammation—including statins and other
immunomodulatory strategies—may be needed in addition to
A, Overall results shown as median (interquartile range). B, Individual data
points before and after combination ART. Bilateral axillary lymph node
target-background ratio (TBR) decreased significantly (P = .01) and aortic TBR
increased significantly (P = .04 by 2-way Wilcoxon signed rank test; P = .98 for
1-way test of decrease by Wilcoxon signed rank test). The lymph node TBR
decreased in 10 of 11 participants, and aortic TBR increased in 8 of 10 after
combination ART. One participant did not undergo [18F]-FDG-PET at the end of
the study, and aortic TBR data on 1 participant could not be used because
significant activity in the thymus caused spillover of activity into the aorta.
Combination ART indicates a regimen of elvitegravir, cobicistat, emtricitabine,
and tenofovir disoproxil fumarate used in this study.

ART. Strengths of our study include the novel application of

[18F]-FDG-PET and CCTA in concert with detailed immune
and metabolic phenotyping before and after new initiation of
a contemporary ART regimen. Limitations of our study
include the relatively small sample size and the absence of
women in the cohort. Furthermore, we used stand-alone
[18F]-FDG-PET imaging with manual coregistration to CCTA
imaging. In addition, the full clinical impact of arterial inflam-
mation as measured by [18F]-FDG-PET in the HIV population
remains unknown.
Conclusions
Studies are needed to examine longer-term, comparative ef-
fects of different ART regimens on arterial inflammation. In
addition, future studies are needed to elucidate the relation-
ship between arterial inflammation, atherogenesis, and myo-
cardial infarction in HIV.

ARTICLE INFORMATION
Accepted for Publication: March 16, 2016.
Published Online: May 25, 2016.
doi:10.1001/jamacardio.2016.0846.
Author Affiliations: Program in Nutritional
Metabolism, Massachusetts General Hospital and
Harvard Medical School, Boston (Zanni, Toribio,
Feldpausch, Martin, Grinspoon); Infectious Disease
Division, Massachusetts General Hospital and California (Melbourne); General Internal Medicine
Harvard Medical School, Boston (Robbins, Triant, Division, Massachusetts General Hospital and
Suchindran); Department of Biology, Boston Harvard Medical School, Boston (Triant);
College, Chestnut Hill, Massachusetts (Burdo, Biostatistics Center, Massachusetts General
Williams); Cardiac Magnetic Resonance–Positron Hospital and Harvard Medical School, Boston (Lee).
Emission Tomography–Computed Tomography Author Contributions: Drs Tawakol and Grinspoon
Program and Division of Cardiology, Department of contributed equally to the study. Dr Grinspoon had
Radiology, Boston, Massachusetts (Lu, Ishai, full access to all the data in the study and takes
Hoffmann, Tawakol); Gilead Sciences, Foster City,

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 Research Brief Report
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Zanni, Tawakol,
Grinspoon.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Zanni, Toribio, Martin,
Tawakol, Grinspoon.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Zanni, Toribio, Martin, Lee,
Grinspoon.
Obtained funding: Zanni, Melbourne, Tawakol,
Grinspoon.
Administrative, technical, or material support: Lu,
Martin, Hoffmann.
Study supervision: Grinspoon.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest. Dr
Zanni participated in a scientific advisory board
meeting for Roche Diagnostics and received grant
support from Gilead Sciences, both unrelated to
this study. Dr Melbourne is employed by Gilead
Sciences. Dr Hoffmann has received grants from
HeartFlow Inc, Siemens Healthcare, Genzyme, and
the American College of Radiology Imaging
Network and personal fees from the American
Heart Association, all unrelated to this study. Dr
Williams served on the scientific advisory board and
was paid by Macrophage Therapeutics LLC,
unrelated to the study. Dr Tawakol served as a paid
consultant for Actelion, Amgen, AstraZeneca,
Cerenis, and Takeda and received grant support
from Actelion, Genentech, and Takeda, all unrelated
to the study. Dr Grinspoon served as a paid
consultant to Gilead Sciences, Theratechnologies,
BMS, NovoNordisk, Merck, Navidea, Aileron, and
AstraZeneca and received grant support from
Amgen, BMS, Gilead Sciences, Kowa
Pharmaceuticals, and Theratechnologies, all
unrelated to the study. No other disclosures were
reported.
Funding/Support: This work was supported by an
investigator-initiated grant from Gilead Sciences to
Dr Grinspoon and by National Institutes of Health
(NIH) grants M01-RR-01066 and 1 UL1 RR025758-
01 to the Harvard Clinical and Translational Science
Center from the National Center for Research
Resources. Dr Zanni was supported by a Medical
Research Investigator Training award from the
Harvard Catalyst/The Harvard Clinical and
480 JAMA Cardiology July 2016 Volume 1, Number 4 (Reprinted)
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Antiretroviral Therapy Effects on Immune Function and CVD Risk in HIV Infection
Translational Sciences Center (National Center for
Research Resources and the National Center for
Advancing Translational Sciences, NIH Award
8KL2TR000168-05). Dr Lu was supported by the
American Roentgen Ray Society Scholarship.
Role of the Funder/Sponsor: The study funders
had no role in the design or conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation of the
manuscript; and decision to submit the manuscript
for publication. Gilead Sciences reviewed the
manuscript prior to submission, but submission was
not contingent on approval by Gilead Sciences.
Disclaimer: The content is solely the responsibility
of the authors and does not necessarily represent
the official views of the NIH or Gilead Sciences.
Additional Contributions: We thank the nursing
staff at the Massachusetts General Hospital Clinical
Research Center as well as the individuals who
participated in this study.
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