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* Division of Pediatric Gastroenterology and Nutrition, University of Rochester Medical Center
Department of Biostatistics and Epidemiology, the Cleveland Clinic Foundation, Cleveland
Department of Medicine, Brigham and Women’s Hospital, Boston
|| Children’s Nutrition Research Center, Texas Children’s Hospital, Houston
¶ Department of Pediatrics, Mount Sinai School of Medicine, New York
** Baylor College of Medicine, Department of Pediatrics, Division of Allergy and Immunology
UCLA Center for the Health Sciences, Los Angeles
Division of Pediatric Cardiology, University of Rochester Medical Center
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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Methods. Children of HIV-1-infected women were enrolled prenatally or within the first 28 days of life. Failure to thrive (FTT) was defined as an age- and sex-adjusted weight z score 
-2.0 SD. Maternal baseline covariates included age, race, illicit drug use, zidovudine use, CD4+ T-cell count, and smoking. Infant baseline predictors included sex, race, CD4+ T-cell count, Centers for Disease Control stage, HIV-1 RNA, antiretroviral therapy, pneumonia, heart rate, cytomegalovirus, and Epstein-Barr virus infection status.
Results. The study cohort included 92 HIV-1-infected and 439 uninfected children. Infected children had a lower mean gestational age, but birth weights, lengths, and head circumferences in the 2 groups were similar. Mothers of growth-delayed infants were more likely to have smoked tobacco and used illicit drugs during pregnancy. In repeated-measures analyses of weight and length or height z scores, the means of the HIV-1-infected group were significantly lower at 6 months of age (P < .001) and remained lower throughout the first 5 years of life. In a multivariable Cox regression analysis, FTT was associated with a history of pneumonia (relative risk [RR] = 8.78; 95% confidence interval [CI]: 3.59–21.44), maternal use of cocaine, crack, or heroin during pregnancy (RR = 3.17; 95% CI: 1.51–6.66), infant CD4+ T-cell count z score (RR = 2.13 per 1 SD decrease; 95% CI: 1.25–3.57), and any antiretroviral therapy by 3 months of age (RR = 2.77; 95% CI: 1.16–6.65). After adjustment for pneumonia and antiretroviral therapy, HIV-1 RNA load remained associated with FTT in the subset of children whose serum was available for viral load analysis.
Conclusion. Clinical and laboratory factors associated with FTT among HIV-1-infected children include history of pneumonia, maternal illicit drug use during pregnancy, lower infant CD4+ T-cell count, exposure to antiretroviral therapy by 3 months of age (non-protease inhibitor), and HIV-1 RNA viral load.
Key Words: human immunodeficiency virus • children • failure to thrive • growth • malnutrition
Abbreviations: HIV-1, human immunodeficiency virus-1 • FTT, failure to thrive • RDA, recommended daily allowance • P2C2, Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV Infection study • ZDV, zidovudine • CDC, Centers for Disease Control and Prevention • CMV, cytomegalovirus • EBV, Epstein-Barr virus • PCP, Pneumocystis carinii pneumonia • NOS, not otherwise specified • CI, confidence interval • RR, relative risk
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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The exact mechanism of failure to thrive (FTT) has not been identified in the pediatric HIV-1-infected population. Factors that influence growth in all children include energy intake, energy metabolism, gastrointestinal absorption, and psychosocial factors. In HIV-1-infected children, preliminary evidence suggests that dietary intakes are adequate because the majority of these children meet or exceed the recommended daily allowance (RDA) for calories and macronutrients.6,7 Some evidence suggests that dietary intakes that are much higher than the RDA can increase the weight of HIV-1-infected children.7 Energy metabolism is less well-defined, but some studies suggest that resting energy expenditure in infected children is slightly higher than predicted,8 which is also the case in adults with HIV-1 infection.9,10 Children with HIV-1 infection are also more likely than noninfected children to have problems absorbing nutrients, which can impair growth.11,12 Comorbidities or chronic clinical conditions associated with HIV-1 can influence growth and nutrition by altering any of the aforementioned factors.
Despite the expanding literature on growth and nutrition in children with HIV infection,1,2,3,4,5 a comprehensive evaluation of prenatal and postnatal associations with FTT in HIV-1-infected children has not been reported. Knowing those factors may enable clinicians to intervene with closer nutritional surveillance in children at risk for FTT. Alternatively, children with FTT may be at risk for comorbid conditions associated with FTT. In this report, we analyzed data from a prospective multicenter pediatric HIV study to identify baseline maternal and infant covariates that may be associated with FTT in children with vertically transmitted HIV-1 infection. A secondary objective was to evaluate the effect of HIV-1 on growth from birth through 5 years of age.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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At birth, 3 months, and 6 months, infant peripheral blood was cultured for HIV-1 according to the AIDS Clinical Trials Group consensus protocol for qualitative peripheral blood mononuclear leukocyte HIV-1 cultures.14 Enzyme-linked immunosorbent assays and Western immunoblot serologic tests were performed when the infants were 15 months old or older; the results were used to confirm HIV-1 infection status. Infants were considered to be HIV-1 infected if they had 2 positive cultures or a positive HIV-1 serologic result at 15 or more months of age, died from an HIV-1-associated condition, or developed acquired immunodeficiency syndrome. Children were considered to be HIV-1 uninfected if they had 2 negative cultures, including 1 at or after 5 months, or if they had a negative antibody test at 15 months of age or older. The noninfected children constituted the comparison population. Because they shared many of the same growth-impairing psychosocial factors with the infected children, we were able to determine the effect of HIV-1 infection on growth patterns. Those who did not meet either criterion were classified as having indeterminate infection status.
Maternal Covariates
HIV-1 infection in the women was confirmed by standard enzyme-linked immunosorbent assay and Western immunoblot serologic testing. Baseline characteristics of the women during pregnancy were evaluated as potential covariates that might have influenced the children’s growth. Demographic information (age, race) and a complete history of the pregnancy and delivery, including prescription medications (eg, zidovudine [ZDV]) and illicit drug use, were collected in a standardized fashion from interviews and medical records.13 Mothers were asked about use of tobacco as well as cocaine, crack, heroin, methadone, marijuana, nitrate inhalants, phencyclidine, amphetamines, and barbiturates. Lymphocyte subsets were determined during pregnancy using an AIDS Clinical Trial Group-certified laboratory.14
Infant and Child Covariates
We recorded baseline demographic features (sex and race) and immunologic factors including CD4+ T-cell counts at baseline (within the first 6 months of life) and Centers for Disease Control and Prevention (CDC) symptom status as determined by the most severe category by 3 months of life.15 Two infants with wasting syndrome before 3 months of age were not included in the CDC symptom status analysis. CD4+ T-cell counts were expressed as age-adjusted z scores.16 Serum HIV-1 RNA concentration was measured in stored samples by quantitative HIV-1 RNA polymerase chain reaction using Amplicor HIV-1 Monitor test (Roche Diagnostic Systems, Branchburg, NJ); 1 technician performed all assays. The lower limit of detection was 400 copies/mL, as previously described.17 Because HIV-1 RNA levels rise sharply in the first 2 months of life and then decline gradually through 24 months,17 the first measurement from each child in this period (2–24 months) was used for analysis. We evaluated left ventricular fractional shortening and mass and heart rate within the first 10 months of life. Respiratory rate was measured over a full minute by a trained observer while the child was awake and breathing quietly. Tachypnea was defined as a respiratory rate at or above the upper 95th percentile for age by 3 months of age.18 Other baseline covariates included postnatal use of antiretroviral therapy by 3 months of age (no children were on protease inhibitors before age 2 or highly active antiretroviral therapy) and disease progression as previously described.19 The children were considered to be rapid progressors if they had an acquired immunodeficiency syndrome-defining condition (other than lymphocytic interstitial pneumonitis/pulmonary lymphoid hyperplasia), severe immunosuppression (CDC category 3), or both in the first year of life. Disease progression categories for infants who died before 1 year of age were assigned based on available symptom and immunology data.
All children were evaluated for cytomegalovirus (CMV) infection by 18 months of age using urine culture with standard virologic techniques (shell vial or standard culture) and serology with commercially available enzyme immunoassays.20 A child who had a positive culture at any age or who had a positive serologic test (immunoglobulin G or M) at 12 months of age or older was considered CMV positive. Patients older than 6 months were considered CMV-negative if they had a negative serologic test and no previous positive culture results. Oropharyngeal swab specimens for Epstein-Barr virus (EBV) were obtained by 18 months of age and assayed using standard techniques.21
Specific criteria for viral and bacterial pneumonia diagnoses have been previously reported.22 Evidence from bronchial lavage fluid or open lung biopsy was needed for a diagnosis of Pneumocystis carinii pneumonia (PCP). Mycobacterial infection was diagnosed when a new radiographic abnormality occurred and a culture from lower-airway secretions or an open lung biopsy specimen showed that the organism was present. If the origin of pneumonia could not be determined, it was designated as not otherwise specified (NOS).
Outcome Measurements
The primary outcome of this study was time to FTT. FTT was defined as an age- and sex-adjusted weight z score of -2.0 SD (ie, a weight that falls at or below 2 standard deviations of the age- and sex-adjusted mean of healthy population standards). Recumbent length and weight were recorded in all children younger than 2 years of age. For those 2 years and older, standing height and weight were recorded. Standard techniques23 were used in all patients. Length or height and weight were determined at each pulmonary physical examination (every 3 months from birth to 18 months and every 6 months thereafter) and at each cardiac assessment (every 4 months for HIV-1-infected children and every 6 months for uninfected children). Because growth endpoints were not the main outcome measurements for the P2C2 HIV protocol, data on parental stature and dietary intake were not available for analysis.
Weight, length or height, and weight for length or height were age and sex adjusted and expressed as z scores using the ANTHRO pediatric anthropometry software program.24
Statistical Analyses
Actual gestational age, birth weight, birth length, birth head circumference, and z scores for these variables were compared by HIV-1 group with the Wilcoxon rank-sum test. z Scores were calculated for birth weight, birth length, and head circumference based on gestational age.25 Baseline weight z scores that were available by 3 months of age were compared separately for HIV-1-infected and HIV-1-uninfected infants by maternal characteristics using the Wilcoxon rank-sum test.
Repeated-measures analyses were performed for actual weight, length or height, and weight for length or height and for the z scores. A linear model using maximum likelihood estimation and a heterogeneous compound symmetry variance-covariance form among the repeated measurements was fit for each outcome. Covariate adjustment was made for HIV-1 group, age category, and HIV-1 group by age category. The results were summarized by HIV-1 group and age category using model-based means and 95% confidence intervals (CIs) obtained from the repeated-measures model.
Cumulative rates of FTT and mortality were estimated with the Kaplan-Meier method, and 95% CIs for FTT were provided for the first 5 years of life by HIV-1 group. Generalized Wilcoxon tests were used to compare overall FTT incidence among HIV-1-infected children according to baseline clinical characteristics. To estimate the relative risk (RR) of FTT and examine the temporal relationship between pneumonia and FTT, we included each type of pneumonia as a time-dependent nominal covariate (yes/no) in a Cox regression model of time to FTT. The Cox regression model was fit separately for each type of pneumonia. FTT rates by disease progression and HIV-1 group and mortality rates by FTT status were compared using the generalized Wilcoxon test. All tests were 2-sided. A P value .05 was considered to indicate statistical significance.
To assess the simultaneous effect of baseline factors on time to FTT, Cox’s proportional-hazards regression model was used. Forward and backward stepwise selection was used to choose prognostic factors for the multivariable model. Only factors that were significant at P .05 in the univariable analyses were included in the multivariable analyses. The RR and its 95% CI were calculated for each factor in the presence of others in the final model.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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Most of the children were black (271/531, 51%) or Hispanic (166/531, 31.3%), and 282 were male (53.1%). There were no differences in sex or race distribution between the infected and uninfected children. Infants were small at birth because mean weight and length z scores were less than zero (P < .001) for both HIV-1-infected and uninfected infants. However, birth weight, length, and head circumference (and z scores of these measurements) were similar among the infected and uninfected infants. Gestational age was lower in the infected infants (mean ± SD, 37.7 weeks ± 2.9) than in the uninfected infants (38.4 weeks ± 2.6; P = .01). By 3 months of age, all infants were alive, and 17 HIV-1-infected infants had received antiretroviral therapy. All 17 received ZDV, and 5 infants received more than 1 antiretroviral therapy.
Table 1 summarizes baseline weight z scores in both the HIV-1-infected and noninfected infants grouped by maternal covariates. Weight z scores for the HIV-1-infected infants were lower if mothers smoked tobacco during pregnancy (P = .001) or used illicit drugs (P = .007) during pregnancy. Weight z scores were also lower in the HIV-1-uninfected infants born to mothers who smoked tobacco during pregnancy (P < .001) or mothers who used illicit drugs during pregnancy (P < .001). Weight z scores among HIV-1-uninfected infants declined as the amount of maternal smoking during pregnancy increased (P = .004). Maternal use of crack, cocaine, or heroin was associated with lower weight z scores among the HIV-1-infected infants (P = .02) and HIV-1-uninfected infants (P < .001).
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Factors Associated With Failure to Thrive in HIV-Infected Children
Cumulative rates of FTT and 95% CIs for the 92 HIV-1-infected children and 439 uninfected children are shown in Fig 2. By 3 months of age, 20.8% (95% CI: 12.5%–29.1%) of HIV-1-infected children had weight z scores below -2.0 SD. By 1 year of age that percentage had increased to 37.3% (95% CI: 27.1%–47.4%). Cumulative rates of FTT in the HIV-1-infected group were 42.2% at 2 years of age and 50.1% at 5 years of age. For the uninfected children, 11.0% (95% CI: 8.0%–13.9%) had weight z scores below -2.0 SD at 3 months of age, with 15.7% (95% CI: 12.3%–19.2%) below -2.0 SD at 2 years of age (P < .001 for the comparison between infected and uninfected children). Although mean weight z scores were lower for HIV-1-uninfected infants born to mothers who smoked tobacco during pregnancy or mothers who used crack, cocaine, or heroin, the FTT rates were not different based on these maternal characteristics.
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Table 3A provides the results from Cox regression analyses for 82 children (38 with FTT). Factors independently associated with FTT were first pneumonia episode; maternal use of crack, cocaine, or heroin during pregnancy; lower CD4+ T-cell count; and any antiretroviral therapy by 3 months of age. In a separate analysis of 75 children that included heart rate z score as a covariate in addition to the factors in Table 3, the association between heart rate and FTT approached statistical significance (RR = 1.26 per 1 SD increase; 95% CI: 0.97–1.64; P = .08).
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Morbidity and Mortality
Figure 3 shows the cumulative mortality for HIV-1-infected children. Children with FTT had higher mortality rates than the children without FTT (36.3% mortality at 36 months compared with 14.3%; P = .02). Figure 4 demonstrates that children who were classified as rapid progressors also had higher rates of FTT (64.5% at 36 months compared with 27.1%; P < .001 by the log-rank test).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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Growth and nutritional problems in HIV-1-infected children were recognized even before HIV-1 was isolated in the early 1980s.26,27 Reports from Africa initially called HIV-1 the "slim disease."28 Although several reports have characterized growth patterns for HIV-1-infected children,1,2,3,4,5 few have reported important both prenatal and postnatal clinical or biochemical associates of growth problems.29 Simple longitudinal analyses of weight and length or height have shown that stable HIV-1-infected children experience a nearly proportionate decline in both length or height and weight but maintain nearly normal ratios of weight for length or height.2,3,4,5 As children become sicker, wasting becomes more clinically obvious. By controlling for the multiple potential confounders that can affect growth, some studies, including the Women and Infants Transmission Study, showed that HIV-1 itself influences both height and weight.4 In the Women and Infants Transmission Study, maternal and neonatal factors were evaluated only at baseline, yet the authors recognized the importance of evaluating postnatal events.
Many factors probably interact to cause growth problems among HIV-1-infected children. The 4 most cited factors are low energy intake, gastrointestinal malabsorption, increased energy expenditure, and psychosocial issues. The extent to which any of these factors adequately explains growth abnormalities in this group of children has not been well- studied. Preliminary evaluations of diet intake in stable HIV-1-infected children have shown that although the majority of children ingest most macronutrients at or above the RDA,6,7 their weights and lengths or heights are below those of age- and sex-matched control children. Diets that contained calories and macronutrients in amounts greater than that suggested by the RDA were associated with greater weights, suggesting that malabsorption or increased energy requirements contribute to the growth abnormalities. Unfortunately, energy expenditure was not simultaneously measured in those studies. Abnormal gastrointestinal absorption of carbohydrate, fat, and protein in children with HIV-1 infection has been well-described, yet there are conflicting reports of its association with growth problems in these children.11,12 In the above-cited studies,7 diarrhea was more prevalent in the smaller children, but gastrointestinal absorption was not formally evaluated.
Psychosocial factors must also be considered for any child with impaired growth. Factors such as an unstable home environment and inadequate emotional and social support have been shown to contribute to growth problems in both HIV-1-infected30 and non-HIV-1-infected children via many mechanisms, including growth hormone deficiencies.31,32 Children with HIV-1 infection are more likely to live with parents who are ill, who have limited access to social services and support, and who have ongoing problems with drug and substance abuse.33 Our result mirror those of Moye et al,4 who found maternal crack and cocaine use during pregnancy to be a predictor of growth and nutritional problems for the child. This finding is not unique for HIV-1; it has been reported in other non-HIV-1 cohorts.34 Children born to drug-using women often are small, suggesting that drugs have a prenatal effect, but the postnatal home environment is likely to influence growth as well. Our finding that 15.7% of the uninfected children experienced FTT by 2 years of age also suggests that environmental factors also affected growth. Unfortunately, our study did not have a comparison group of children without exposure to HIV-1, which could have helped us differentiate between the effects of social factors and HIV-1 exposure.
Increased energy use can affect growth for all children. Even an asymptomatic chronic viral infection can affect energy use and predispose children to secondary infections, which can alter energy use patterns. These infections can increase or shunt effective use of energy substrates from normal, healthy growth patterns to abnormal ones, as occurs in many children with chronic illness, including cystic fibrosis, inflammatory bowel disease, congenital heart disease, and childhood cancer.35,36,37 Our study determined that time to pneumonia and lower CD4+ T-cell count are significantly associated with FTT. In addition, HIV-1 RNA load was also associated with FTT. These findings support the hypothesis and early findings that higher HIV-1 loads and secondary infections are associated with growth problems in these children. It is possible that other unmeasured factors, such as serum cytokines, which may change with viral load and can alter metabolism, contribute to the growth changes associated viral load and CD4 counts.
Few studies have evaluated energy use in children with HIV-1, and small sample sizes limit the interpretation of the results.8,38,39,40 In adults with HIV-1 infection, even those with minimal symptoms have a resting energy expenditure that increases with advancing HIV-1 stage.9,10 Few studies have evaluated total energy expenditure in adults or children,39,40,41 yet total energy expenditure does not appear to be different between HIV-1-infected children with growth failure, as defined by a linear growth velocity of less than the 5th percentile,39,40 and those without growth failure.
Antiretroviral therapy (nonprotease inhibitor) was independently associated with FTT in our cohort, although it may be a surrogate for more advanced disease. This association has been found in other studies.4,7 ZDV, in particular, alters mitochondrial metabolism42 and may have direct nutritional effects in addition to acting as a surrogate marker for more advanced HIV-1 disease. Additional studies should focus on the effects of ZDV and other antiretroviral therapy on nutritional status.
This study did not evaluate the effects of protease inhibitor or highly active antiretroviral therapy on growth in children with HIV-1 because the cohort was recruited and followed before the therapy became widely available. Yet there is evidence that protease inhibitor therapy positively influences nutritional status, including improving body composition.43 There may have been other factors, such as neurologic deficits, that can influence growth yet were not recorded in the study because it was not designed with growth changes as a primary outcome. However, this study included a large, systematically studied group of HIV-1-infected infants, tracked from birth with close follow-up of important clinical variables. In addition, the multicenter, national distribution of black, Hispanic, and white children makes this study more generalizable to children throughout the world than any single or regional study.
Our study provides important preliminary data that can help providers identify HIV-1-infected children who are at risk for FTT or who may develop comorbid conditions as a result of FTT. We hope that knowledge of these associations will enable practitioners to intervene earlier with closer nutritional surveillance or earlier institution of supplemental feedings to prevent additional morbidity and mortality in these children. Likewise, FTT may be associated with comorbid conditions such as pneumonia. The clinician should be aware of potential medical complications associated with FTT. Future studies should evaluate growth and long-term nutritional consequences of highly active antiretroviral therapies in children and should test nutritional interventions in high-risk children.
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APPENDIX |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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Chairman, the Steering Committee: Robert Mellins, MD
Clinical Centers
Baylor College of Medicine, Houston, Texas: William Shearer, MD, PhD*; I. Celine Hanson, MD, Linda Davis, RN, BSN; Ruth McConnell, RN, BSN. University of Texas School of Medicine: Marilyn Doyle, MD; Debra Mooneyham, RN; Teresa Tonsberg, RN
Children’s Hospital/Harvard Medical School, Boston, Massachusetts: Steven Lipshultz, MD*; Kenneth McIntosh, MD; Janice Hunter, MS, RN. Boston Medical Center: Suzanne Steinbach, MD; Ellen Cooper, MD
Mount Sinai School of Medicine, New York, New York: Meyer Kattan, MD*; David Hodes, MD; Diane Carp, MSN, RN. Beth Israel Medical Center: Stephen Heaton, MD; Mary Anne Worth, RN
Presbyterian Hospital in the City of New York/Columbia University, New York, New York: Robert Mellins, MD*; Jane Pitt, MD; Kimberly Geromanos, RN, MS, CNS
UCLA School of Medicine, Los Angeles California: Samuel Kaplan, MD*; Helene Cohen, RN, PNP. Children’s Hospital, Los Angeles: Joseph Church, MD; Arnold Platzker, MD; Lucy Kunzman, RN, MS; Toni Ziolkowski, RN. LAC/USC: Andrea Kovacs, MD; Lynn Fukushima, MSN, RN
Clinical Coordinating Center
The Cleveland Clinic Foundation, Cleveland, Ohio: Kirk Easley, MS*; Michael Kutner, PhD* (through 1999); Mark Schluchter, PhD* (through 1998); Johanna Goldfarb, MD; Richard Martin, MD (Case Western Reserve University); Douglas Moodie, MD; Sunil Rao, PhD; Amrik Shah, ScD; Cindy Chen, MS; Scott Husak, BS; Victoria Konig, ART; Paul Sartori, BS; Susan Sunkle, BA; Weihong Zhang, MS
Policy, Data, and Safety Monitoring Board
Henrique Rigatto, MD (Chairman); Edward B. Clark, MD; Robert B. Cotton, MD; Vijay V. Joshi, MD; Paul S. Levy, ScD; Norman S. Talner, MD; Patricia Taylor, PhD; Robert Tepper, MD, PhD; Janet Wittes, PhD; Robert H. Yolken, MD; Peter E. Vink, MD
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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The institutions and investigators participating in this study are listed in the "Appendix."
Reprint requests to (T.L.M.) Division of Pediatric Gastroenterology and Nutrition, Box 667, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642. E-mail: tracie_miller{at}urmc.rochester.edu
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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This article has been cited by other articles:
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  S. K. Grinspoon, C. Grunfeld, D. P. Kotler, J. S. Currier, J. D. Lundgren, M. P. Dube, S. E. Lipshultz, P. Y. Hsue, K. Squires, M. Schambelan, et al. State of the Science Conference: Initiative to Decrease Cardiovascular Risk and Increase Quality of Care for Patients Living With HIV/AIDS: Executive Summary Circulation, July 8, 2008; 118(2): 198 - 210. [Full Text] [PDF]
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M. P. Dube, S. E. Lipshultz, C. J. Fichtenbaum, R. Greenberg, A. D. Schecter, S. D. Fisher, and for Working Group 3 Effects of HIV Infection and Antiretroviral Therapy on the Heart and Vasculature Circulation, July 8, 2008; 118(2): e36 - e40. [Full Text] [PDF]
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