P. Chandrasekaran , A. Shet, K. Ramesh, P.K.Bhavani,

High prevalence of PLIN gene & Metabolic risk factors among Children initiating Antiretroviral therapy in south India P. Chandrasekaran, A. Shet, K. Ramesh, P.K.Bhavani, R. Srinivasan, G. Sanjeeva, P. Gangadevi, E. Suresh, C. Chandrasekar, C. Wanke, S. Swaminathan National Institute for Research in Tuberculosis (ICMR), India

Introduction • Antiretroviral therapy • Overall reduction of morbidity & mortality • lead to development of Metabolic syndrome / HIV Associated Lipodystrophy Syndrome (HALS) • Similar exposure to drugs, diet, socioeconomic status, not every child on ART develops HALS • Host Genetic factors

Host Genetic factors & HALS • Polymorphisms in APOA5 APOC3, APOE & CETP • Perilipin gene (PLIN), major protein coating intracellular lipid droplets , modulates adipocyte lipolysis • Minor allele at PLIN 11482 (G>A) is associated with • higher risk of metabolic syndrome • - Higher TGL / Lower HDL-c / Higher insulin resistance • No Indian Studies Arnedoa M et al.. Pharmacogenetics and Genomics 2007, Ordovas JM et al. Curr Opin Lipidol 2007; 18: 152 Qi L et al. Clin Genet 2004;

India “HALS” study • Prospective study • To determine the incidence & risk factors of dyslipidemia, insulin resistance & body shape changes • Children 2-12 years, initiating ART (2NRTI + 1 NNRTI) • NIRT, Chennai & SJRI, B’lore

Objectives • To assess the baseline risk factors of metabolic syndrome, namely blood lipid profile, glucose, insulin resistance and waist: hip ratio, among children before they initiate first-line antiretroviral therapy • To look for the presence of polymorphisms of specific gene PLIN - associated with metabolic syndrome - in these children

Data collection • Anthropometry, body circumferences & skinfold thickness • 24-hour dietary recall and Food security • Fasting blood for Serum lipids, Glucose, Insulin, high-sensitivity C-reactive protein (hs-CRP) • CD4 cell count & HIV-1 viral load • PLIN Gene polymorphisms RT- PCR • Homeostatic model assessment-Insulin resistance (HOMA-IR) estimated using the formula [fasting glucose (mg/dL) X insulin (uU/mL)]/405

Study population • 218 Children living with HIV infection • mean age: 8 + 3 years (2-12years) • mean body weight : 18 + 6 kgs • mean CD4%: 15% (1-54%) • median viral load : 179,136 copies/ml (46,090 – 574,494) • 60% WHO Clinical Stage III or above • 16% co-infected with Tuberculosis

Study population • 97% through Vertical Transmission • Only 35% mothers diagnosed antenatal • 61% were vaccinated up-to-date • 40% households food insecure • 15% in foster-care • Triple drug therapy, with 2NRTI + 1NNRTI • Regimen containing d4T : 48 / AZT :154 / ABC 16

Nutritional Indicators • Stunting or chronic malnutrition reflects past shortage of food intake or chronic illness - negatively and irreversibly affects linear growth, organ growth & cognition • Underweight – composite indicator of both past & present under nutrition (measure of MDG)

Risk Factors of Metabolic Syndrome 1. Fasting Blood Lipids • Hypocholesterolemia seen in majority of CLHIV • 87% of children having low HDL-c • Serum Triglycerides > 150 mg/dl seen in 37% CLHIV • Waist: Hip ratio 0.96 (WNL)

Risk Factors of Metabolic Syndrome 2. Insulin Resistance • HOMA-IR > 3.5 in 13% of children at baseline • hs-CRP of 3-10 mg/dl in 22% • - indicators of high risk for metabolic syndrome

3a. PLIN Gene Polymorphisms • PLIN 11482 minor allele (GA+AA) associated with • significant higher sr. triglycerides level at baseline

Discussion • Even before ART initiation, risk factors for Metabolic syndrome seen in HIV-infected ART-naive children in South India • serum triglycerides > 150mg/dl : 81 children (37%) • HDL-cholesterol < 40mg/dl: 189 children (87%) • HOMA-IR > 3.5 : 29 children (13%) • hs-CRP 3-10mg/dl : 22% of children

Discussion • In our cohort of CLHIV, minor allele A at PLIN4 11482G>A, which is associated with increased risk of MS, seen in 55% (103/189) of children • At baseline, among those with raised triglycerides, 68% (50/74) had minor allele A • Among those with normal TGL 46% (53/113) had minor allele A at PLIN4 11482G>A • PLIN 6209T>C, PLIN13041A>G did not find any association in our cohort

Conclusion • Despite background of food insecurity and malnutrition, substantial number of HIV-infected ART-naive children are at high risk for development of Metabolic Syndrome • Given the relatively large number of carriers of genetic risk variants in this group, children with advanced disease need to be closely monitored for the development of MS, once ART is initiated • Prevent long-term morbidities. Study is ongoing

Acknowledgements Tufts University, Boston • Dr. Christine A Wanke, • Dr. Jose Ordovas St. John’s Research Institute, B’lore • Dr. Anita Shet Indira Gandhi Hospital, Bangalore • Dr. GN Sanjeeva Ro1 AI084390 • All study participants • ART centre Medical Officers

P. Chandrasekaran , A. Shet, K. Ramesh, P.K.Bhavani,