India: Vellore

Street entrance to Christian Medical College, Vellore India

Nutritional and Metabolic Issues in HIV in India/Translational Virology Core

Although antiretrovirals are now available at relatively low cost in India, the use of highly active antiretroviral therapy is not yet common. Until the infrastructure for delivering and monitoring HAART and training of physicians/providers in the initiation, monitoring and sequencing of HAART regimens is more established, the use of HAART may not grow to its fullest need. Until HAART is widely available, the presentation of HIV/AIDS in India is one of wasting, respiratory disease and diarrheal diseases: the same infectious illnesses that have comprised such an enormous disease burden in children in this region, even before the HIV epidemic. The CFAR is utilizing its long-term collaborations with investigators with extensive experience in intestinal function and diarrheal disease in India at the Christian Medical College (CMC) in Vellore, Tamilnadu to address these issues as they present in adults and children with HIV.

While CMC is internationally known for its expertise and investigations in intestinal function and enteric infections, the interface between these and HIV- infection had not been explored in depth. With the support of the CFAR and the Fogarty Training Grant, Dr. Wanke has been working to provide opportunities to investigators to begin investigations of intestinal function and diarrheal illness in HIV at CMC. Protocols to investigate malabsorption in HIV infected adults and to examine the precise cryptosporidial biotypes that are contributing to diarrheal disease and that allow asymptomatic carriage of the parasites in HIV infected adults in this region have been implemented. A protocol examining the impact of HIV on the malnutrition seen in tuberculosis is in place and an intervention trial to attempt to alleviate the malnutrition is being developed. The exchange of complementary expertise between YRG Care and CMC is occurring and collaborations between the 2 institutions in South India are developing, fostered by the CFAR and the Fogarty

In the developed world, the use of HAART came abruptly without a recognition of the potential for long-term complications and metabolic impact.. Dr. Wanke has been working with investigators at YRG care to ensure that there is an accurate survey of the nutritional and metabolic status of HIV-infected adults prior to the initiation of HAART at YRG Care in Chennai. As the possibility of widespread HAART use has become real in the resource-limited world, it is critical to examine the metabolic impact of chronic HIV infection and its therapies to ensure that the regimens recommended in the population at large are the regimens that are going to provide the most durable benefit and that are the least likely to contribute to metabolic complications. One of the major concerns raised about the metabolic complications of HIV and its therapies is that these will contribute to an increased risk for cardiovascular disease in HIV-infected populations. As the risk for cardiovascular disease and insulin resistance/glucose intolerance/ type II diabetes is so very high in South India in general, it is important to understand the impact of HIV and its therapies on this metabolic substrate, which may be very different from that seen in other parts of the world. As the risk for cardiovascular disease, the dyslipidemia and the glucose intolerance seen with HIV therapy all depend on host and the specifics of the HAART regimen, there is much to learn from the therapy-naïve population in South India that will have major importance on the ultimate success of HIV therapy. Host factors such as genetic predisposition, diet, level of physical activity, baseline body composition and nutritional status may all play an important role in determining the metabolic response to HIV and to specific antiretroviral agents. One of the cardiovascular risks most recognized in HIV infection is a low level of HDL cholesterol; this abnormality appears to be exacerbated by antiretroviral agents, specifically some of the protease inhibitors. The impact of HAART regimens utilizing non-nucleoside reverse transcriptase inhibitors (NNRTI) on cholesterol profiles and on glucose tolerance is being examined in a study at YRG Care in collaborations fostered by the CFAR and the Fogarty.

Globally, with the availability and appropriate use of HAART, HIV can and will evolve into a chronic, manageable disease. It is imperative that providers around the world are able to anticipate and be prepared with sufficient knowledge about the full impact of the HAART regimens in common use to minimize the additional risks and maximize the quality and duration of life for HIV infected individuals. The nutritional and metabolic studies supported in South India by the CFAR will assist in making this goal a realistic one.