HIV

Kaku So-Armah, PhD, on HIV and Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of death around the world and claims an estimated 17.9 million lives per year.1 Relative to the general population, people living with HIV infection have an increased risk of CVD.2

It is important to consider geographical location when assessing CVD risk among people with HIV because it is associated with differences in the distribution of CVD risk factors in different parts of the world, wrote the authors of a new review published in The Lancet HIV.3 Of the approximately 37.9 million people living with HIV globally, 25.6 million live in sub-Saharan Africa, the authors said.3

While traditional risk factors for CVD such as smoking and hypertension are well-known, it is important to take into account non-traditional risk factors for CVD as well, they added.3 Compared with people living in areas including North America and Western Europe, where the majority of HIV- and CVD-related research has been performed, people living in sub-Saharan Africa are younger, smoke less, have a lower prevalence of elevated cholesterol, and have a higher prevalence of elevated blood pressure.3

Infectious Diseases Consultant spoke with lead author Kaku So-Armah, PhD, assistant professor at Boston University School of Medicine, who discussed the importance of considering geographical location and non-traditional CVD risk factors when evaluating CVD risk among people with HIV living in different parts of the world.

ID CON: Could you discuss the importance of considering differences in the distribution of traditional cardiovascular disease risk factors based on geographic location and related factors?

Dr So-Armah: Understanding the distribution of traditional CVD risk factors in specific geographic contexts is important from a public health perspective. This allows health officials to determine where to concentrate efforts to efficiently reduce CVD risk at a population level.

For example, our review highlights an important difference between the American Heart Association’s (AHA) statement and the South African Heart Association’s statement regarding HIV and CVD risk.3 The AHA considers HIV and HIV-related factors as CVD–risk-enhancers and recommends more aggressive monitoring and treatment among people with HIV compared with similar people without HIV.3 However, the South African Heart Association does not consider people with HIV to be at increased risk for CVD because people with HIV in that setting tend to be younger and do not have more cardiometabolic disease than people without HIV in that setting.3

ID CON: Could you elaborate on the non-traditional cardiovascular risk factors many people with HIV face and their significance?

Dr So-Armah: Traditional CVD risk factors typically refer to those found in CVD risk calculators, such as those from the Framingham Heart Study and others. Non-traditional CVD risk factors include:

  • Heavy drinking, which leads to alcoholic cardiomyopathy and other forms of CVD. Alcohol may be uniquely harmful in HIV,4 and more heavy drinking is reported among people living with HIV.
  • Co-infections, including Chlamydia pneumoniae, cytomegalovirus, and periodontitis linked to atherosclerosis. Because HIV is a disease of immunodeficiency, it may increase susceptibility to these infections and inability to control the infection.
  • Polypharmacy, which increases risk for adverse drug-drug interactions with potential cardiovascular side effects. On average, people with HIV are prescribed more pharmacologic drugs than people in the general population.5
  • Mental health. My colleagues and I, as well as, others have linked depression to CVD.6

 
ID CON: What key takeaways do you hope to leave with infectious disease specialists on this topic?

Dr So-Armah: First, I would like to thank all infectious disease specialists for their tireless work with the HIV pandemic, and also for all the work they are doing during the COVID-19 pandemic. Keep doing what you are doing–prevent HIV, treat early, reduce viremia, and prevent immune suppression. These not only help reduce mortality, but the data suggest they also contribute to reducing CVD risk.

Finally, continue assessing CVD risk among your patients with HIV when suitable, and advise or refer as appropriate. Online calculators can be used to calculate CVD risk with the understanding that these calculators may underestimate risk.7,8,9

ID CON: What is the next step in terms of future research in this area?

Dr So-Armah: In future research endeavors, we will need to determine how to take what we already know about the prevention and treatment of CVD, and then tailor and implement it in the parts of the world with the greatest HIV burden. We will also need to determine effective methods of reducing smoking among patients with HIV. Finally, future research initiatives should investigate how HIV contributes to CVD risk particularly in understudied populations, including women, people in sub-Saharan Africa, and people with substance use disorders; and in different types of CVD, such heart failure, peripheral artery disease, and sudden cardiac death.

—Christina Vogt

References:

  1. World Health Organization. Cardiovascular diseases. https://www.who.int/health-topics/cardiovascular-diseases/#tab=tab_1 Accessed May 21, 2020.
  2. Feinstein MJ, Hsue PY, Benjamin LA, et al; on behalf of the American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention and Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council. Characteristics, prevention, and management of cardiovascular disease in people living with HIV: a scientific statement from the American Heart Association. Circulation. Published online June 3, 2019. doi:10.1161/CIR.0000000000000695
  3. So-Armah K, Benjamin LA, Bloomfield GS, et al. HIV and cardiovascular disease. Lancet HIV. 2020;7(4):E279-E293. doi:10.1016/S2352-3018(20)30036-9
  4. Justice AC, McGinnis KA, Tate JP, et al. Risk of mortality and physiologic injury evident with lower alcohol exposure among HIV infected compared with uninfected men. Drug Alcohol Depend. 2016 Apr 1;161:95-103. doi:10.1016/j.drugalcdep.2016.01.017
  5. Edelman EJ, Gordon KS, Glover J, McNicholl IR, Fiellin DA, Justice AC. The next therapeutic challenge in HIV: polypharmacy. Drugs Aging. 2013;30(8):613-628. doi:10.1007/s40266-013-0093-9
  6. So-Armah K, Gupta SK, Kundu S, et al. Depression and all-cause mortality risk in HIV-infected and HIV-uninfected US veterans: a cohort study. HIV Med. 2019;20(5):317-329. doi:10.1111/hiv.12726
  7. Center of Excellence for Health, Immunity and Infections. Risk Assessment Tool System (RATS). https://chip.dk/Tools-Standards/Clinical-risk-scores. Accessed May 21, 2020.
  8. American College of Cardiology. ASCVD Risk Estimator Plus. http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/. Accessed May 21, 2020.
  9. Framingham Heart Study. Framingham Heart Study Primary Risk Functions. https://framinghamheartstudy.org/fhs-risk-functions/. Accessed May 21, 2020.