Cholesterol and Triglyceride Problems

Part of An HIVer's Guide to Metabolic Complications

Not all metabolic complications affect body shape. HIV medications, as well as HIV itself, can also hurt your ability to process two key types of chemicals inside your body: cholesterol and triglycerides.

Although your body needs cholesterol and triglycerides to keep you healthy, if you have abnormal levels of either in your bloodstream, it can lead to problems such as coronary heart disease and stroke. (Coronary heart disease is a condition in which the arteries that supply the heart with blood become blocked. A stroke occurs when there is blockage in an artery supplying blood to the brain.)

What Is Cholesterol?

Most of us think of cholesterol as a bad thing, but cholesterol, a fat-like substance, is a critical building block of cells and many hormones. The problem arises when you have abnormal levels of cholesterol.

Cholesterol is carried through your body in tiny globs called "lipoproteins." There are two main types of lipoproteins:

  • HDL -- or "high-density lipoprotein" -- is called "good" cholesterol, because HDL actually helps keep cholesterol from building up in your arteries. In this way, HDL protects against heart disease. In the case of HDL, the higher your levels are, the better; unfortunately, HDL levels are usually low in people with HIV.

  • LDL -- or "low-density lipoprotein" -- is called "bad" cholesterol, because it delivers cholesterol to different parts of your body. Again, this is not automatically a bad thing, but the more LDL is in your bloodstream, the more likely it is to build up and eventually block your arteries. LDL levels may be low in people with advanced, untreated HIV disease, but levels can rise when a person starts taking HIV meds.

Measuring Cholesterol

Because high cholesterol doesn't have any symptoms -- at least in its early stages -- it is important to have your cholesterol tested. In fact, everyone who is over the age of 20 -- whether HIV positive or not -- should have his or her cholesterol tested at least once every five years. You should test more often if your cholesterol levels are found to be high or if you have other risk factors for heart disease (for example, diabetes, a family history of early heart attacks or strokes, high blood pressure or cigarette smoking). HIV docs should test your cholesterol and triglycerides before prescribing an HIV regimen, repeat the tests within three to six months after you start the regimen, and then take new tests every year as long as your levels stay near normal.

The table below describe normal and high cholesterol levels. However, for people who have a higher risk of heart disease, doctors recommend aiming for lower-than-normal levels of total and LDL cholesterol.

Your Cholesterol Levels: What Do the Numbers Mean?*
LDL Cholesterol LevelCategory
Less than 100Normal
100-129Almost normal
130-159Borderline high
190 and aboveVery high
Total Cholesterol (LDL + HDL)Category
Less than 200Normal
200-239Borderline high
240 and aboveHigh

* If you have risk factors for heart disease, such as high blood pressure, smoking or diabetes, your doctor may recommend that you maintain lower than normal LDL cholesterol and triglycerides.

What Causes High Cholesterol?

For the most part, HIV-positive people develop high cholesterol for the same reasons that HIV-negative people do. In fact, studies have shown that HIV disease and HIV medications are not the most common causes of coronary heart disease in people with HIV. So what are they?

Genetics. Do heart attacks and strokes run in your family?

Age. The older you get, the higher your risk.

Diet. Too much high-cholesterol, high-fat food -- especially saturated and trans fat -- is bad for you.

Smoking. This is the biggest risk factor you have control over.

Diabetes. No matter what caused you to develop it, diabetes greatly increases your risk.

High blood pressure. This can be worsened by stress, excessive drinking or being overweight.

Gender. Men are at higher risk.

Race. African Americans are at higher risk.

Weight. The more you weigh, the more danger you're in.

Physical activity. Less exercise can put you at greater risk.

Which HIV Meds Are to Blame?

While not as big a risk factor as those listed above, research shows that some HIV meds can raise your LDL cholesterol levels. These are some of the best-known culprits:

  • Norvir

  • Agenerase

  • Kaletra

  • Aptivus

  • Lexiva

  • Viracept

  • Crixivan

  • Invirase

  • Zerit

Although avoiding the HIV meds that may raise LDL cholesterol could be a smart move if you already have high cholesterol, talk this over with your doctor first; remember that HIV meds are only one of many potential factors that increase a person's risk of heart disease or stroke.

Doctor's Notes

Dr. David Wohl, University of North Carolina-Chapel Hill
Dr. David Wohl
University of North Carolina-Chapel Hill
When it comes to raising cholesterol and triglycerides, not all protease inhibitors are created equal. For instance, Invirase does so less than most other protease inhibitors, and Reyataz hardly at all. Likewise, not all people respond to HIV medicines in the same way. Some will see an increase in triglycerides, some a rise in LDL cholesterol and others will have neither. Plus, drugs other than protease inhibitors can raise cholesterol and triglycerides. This is why it is important that all people taking HIV medications make sure to have their cholesterol and triglycerides checked regularly.

What Can You Do About High Cholesterol?

In most cases, doctors treat high cholesterol the same way for people with HIV as they do for people without HIV. Your doctor will probably strongly urge you to:

  • Stop smoking, if you smoke.

  • Switch to a healthier diet, if you're overweight or don't eat well.

  • Start exercising regularly, if you're not physically active.

If these lifestyle changes don't work, aren't an option for you, or if your health risk is so high that you need to improve your cholesterol levels quickly, then you and your doctor should talk about medical solutions. The two most common are:

Prescription Meds

There are a few types of medications that a doctor can prescribe to help lower your cholesterol. The most widely used -- and the most effective -- is a group of meds called statins. These include Lipitor, Pravachol and Zocor. Unfortunately, although statins generally work well at lowering LDL cholesterol, certain HIV medications can interfere with them, especially the class of HIV meds known as protease inhibitors (many of which happen to contribute to high LDL cholesterol). Before taking any statins, be sure to discuss possible drug interactions with your doctor.

Besides statins, there are several other types of cholesterol-lowering meds, including fibrates (such as Lopid and Tricor) and prescription-strength niacin (also called nicotinic acid or vitamin B3).

Switching HIV Meds

If you are on an HIV medication that is raising your LDL cholesterol, you and your doctor may decide to replace it. For instance, if you are on a protease inhibitor that is known to raise LDL cholesterol, you may be able to switch to Reyataz (a more cholesterol-friendly protease inhibitor), Sustiva or Viramune.

Before you switch meds, though, be sure to talk things over in detail with your doctor. There are many factors to consider when thinking about a switch, including the risk that your new meds won't suppress your HIV as well as your old meds did and the risk of a new set of side effects.

How About Triglycerides?

Early in the epidemic, before there were HIV medications, doctors noticed that people with AIDS had high triglyceride levels in their blood. Therefore, advanced HIV infection itself is a cause of elevated triglycerides. But, it has also become clear that the same HIV medications that can increase LDL cholesterol, can also raise triglyceride levels. Triglyceride increases may be particularly common in people taking regimens that include Norvir.

What Are Triglycerides?

Just like cholesterol, triglycerides are a type of fat. When you eat a meal, your body converts the food you eat into energy. Any excess energy is then converted into triglycerides and stored so your body can use it later.

High triglyceride levels can increase your risk for heart disease, as well as a dangerous health problem known as pancreatitis, which can damage your pancreas (an organ that your body needs in order to digest foods and convert them into energy).

Measuring Triglycerides

In order to find out what your triglyceride levels are, a doctor will take a sample of your blood and perform what's called a "lipoprotein analysis" on it. The following is a table of triglyceride ranges:

Triglyceride LevelCategory
Less than 150Normal
150 to 199Borderline high
200 to 499High
500 and aboveVery High

What Can You Do About High Triglycerides?

For the most part, high triglycerides can be treated the same way that high cholesterol is treated: with changes in smoking habits (quit!), diet (reduce carbohydrates and sweet stuff!) and exercise (do it!).

Drinking alcohol can also cause high triglycerides, so cutting down on (or stopping) the number of drinks you have can also make a difference.

If these steps fail, some cholesterol-lowering medications -- particularly fibrates, such as Lopid and Tricor -- can help lower triglycerides as well.

Studies also suggest that fish oils, also called omega-3 fatty acids, can lower triglyceride levels in people with HIV. (Fish oil can be taken as a supplement in capsule form; some doctors recommend 1,000 mg to 3,000 mg per day.)

Finally, if you're taking HIV medications that are responsible for raising your triglyceride levels, you may want to talk with your doctor about the possibility of switching HIV medications.

Doctor's Notes: Fish Oils Can Help

Dr. David Wohl, University of North Carolina-Chapel Hill
Dr. David Wohl
University of North Carolina-Chapel Hill
Omega-3 fatty acids, also called fish oils, from marine animals have been found to lower triglycerides and reduce the risk of heart attack in HIV-negative people. Studies in HIVers have found that 3 g of fish oil a day lowers triglycerides by about 25% and is well tolerated. However, in one of the studies, LDL cholesterol increased by more than 20% -- something that we've also seen, although to a lesser degree, with prescription medications used to lower triglycerides. For people who do not have a very high LDL but who do have elevated triglycerides, fish oil is an alternative to medications. Unfortunately, it is typically not covered by medication insurance, so cost can be a problem.

Do HIV Meds Increase Your Risk of Heart Attack?

The short answer is: Probably, but only a little bit.

Since many HIV medications are known to raise LDL cholesterol and triglycerides, experts have suspected that they would also increase the odds of heart problems. The best study of the effect of HIV meds on heart attacks enrolled almost 30,000 people with HIV in North America and Europe. The researchers found that people who were on HIV treatment had an increased risk of heart attacks -- however the overall risk of heart attack was still very low (less than 150 of the 30,000 people actually had a heart attack).

Even with this slightly higher risk of heart attack, the obvious health benefits of taking HIV medications easily trump the very small heart attack risk from the meds themselves.