Cardiovascular and cerebrovascular events in patients treated for human immunodeficiency virus infection

A review of cardiovascular and renal function monitoring: a consideration of older adults with HIV

The prevalence of human immunodeficiency virus (HIV) infection in older and elderly adults is significant worldwide. This population poses new challenges and opportunities in the management of HIV. In addition to the risks affecting HIV patients of all ages, including risk of opportunistic infection and medication resistance, age-related changes in physiology, higher comorbidity burdens, increased use of medications, and potential adverse drug reactions to HIV medications all factor into the care of older adults with HIV. The risk and progression of cardiovascular and renal comorbidities may be higher in the older adult HIV population and in patients taking specific HIV medications. Understanding these risks is essential when managing a new type of patient: the older adult with HIV.

Cardiovascular risk among HIV-positive subjects preceding exposure to HAART: a retrospective claims analysis

Background: Cardiovascular disease (CVD) causes significant morbidity and mortality in HIV-infected individuals. Advancing age, chronic HIV-associated inflammation and antiretroviral therapy in part contributes to the increased risk of CVD in these patients. Aim: This study aimed to compare the CVD- and HIV-related morbidity of subjects prior to initiating an non-nucleoside reverse transcriptase inhibitor (NNRTI)- versus a protease inhibitor (PI)-based HAART regimen. Methods: Subjects in this retrospective, observational study of medical claims data representing HIV-infected beneficiaries from May 2000 to December 2009 were assigned either to a PI initiator group (n = 2192) or to a NNRTI initiator group (n = 3338). The case mix similarities and differences between the two groups were compared. Results: More subjects in the PI group had previous treatment with nucleoside reverse transcriptase inhibitor therapy or with the fusion inhibitor enfuvirtide, whereas more subjects in the NNRTI group had prior treatment with lamivudine plus zidovudine. Uncontrolled Type 2 diabetes, substance abuse, drug dependence, cardiovascular morbidity, heart failure, nonhypertension kidney dysfunction, depression, AIDS-related diagnosis, Kaposi‘s sarcoma, candidiasis and cachexia were observed more often in the PI group. Subjects in the PI group were more likely to be receiving medications for AIDS conditions. Only smoking cessation medication showed a higher prevalence in the NNRTI group. Conclusion: Subjects initiating PI-based versus NNRTI-based therapy had a greater prevalence of specific comorbidities that may adversely affect CVD risk profile.

Vitamin D deficiency is associated with coronary artery calcification in cardiovascularly asymptomatic African Americans with HIV infection

OBJECTIVE

Patients with HIV infection are at increased risk for coronary artery disease (CAD), and growing evidence suggests a possible link between vitamin D deficiency and clinical/subclinical CAD. However, the relationship between vitamin D deficiency and coronary artery calcification (CAC), a sensitive marker for subclinical CAD, in those with HIV infection is not well investigated.

METHODS

CAC was quantified using a Siemens Cardiac 64 scanner, and vitamin D levels and the presence of traditional and novel risk factors for CAD were obtained in 846 HIV-infected African American (AA) participants aged 25 years or older in Baltimore, MD, USA without symptoms or clinical evidence of CAD.

RESULTS

The prevalence of vitamin D deficiency (25-hydroxy vitamin D <10 ng/mL) was 18.7%. CAC was present in 238 (28.1%) of the 846 participants. Logistic regression analysis revealed that the following factors were independently associated with CAC: age (adjusted odds ratio [OR]: 1.11; 95% confidence interval [CI]: 1.08-1.14); male sex (adjusted OR: 1.71; 95% CI: 1.18-2.49); family history of CAD (adjusted OR: 1.53; 95% CI: 1.05-2.23); total cholesterol (adjusted OR: 1.006; 95% CI: 1.002-1.010); high-density lipoprotein cholesterol (adjusted OR: 0.989; 95% CI: 0.979-0.999); years of cocaine use (adjusted OR: 1.02; 95% CI: 1.001-1.04); duration of exposure to protease inhibitors (adjusted OR: 1.004; 95% CI: 1.001-1.007); and vitamin D deficiency (adjusted OR: 1.98; 95% CI: 1.31-3.00).

CONCLUSION

Both vitamin D deficiency and CAC are prevalent in AAs with HIV infection. In order to reduce the risk for CAD in HIV-infected AAs, vitamin D levels should be closely monitored. These data also suggest that clinical trials should be conducted to examine whether vitamin D supplementations reduce the risk of CAD in this AA population.

Cardiovascular involvements in HIV-infected patients

The lifespan of HIV-infected patients is increasing, and cardiovascular diseases becoming a major comorbidity and leading cause of death in this population due to high prevalence of the cardiac risk factors and possibly due to the use of antiretroviral therapy. Aggressive reduction of these risk factors and treatment of cardiovascular diseases are crucial to decrease the cardiovascular mortality in these patients.

HAART-associated dyslipidemia varies by biogeographical ancestry in the multicenter AIDS cohort study

Highly active antiretroviral therapy (HAART) has been successful in delaying the progression to AIDS in HIV-1-infected individuals. Exposure to HAART can result in metabolic side effects, such as dyslipidemia, in a subset of recipients. Longitudinal data and frozen peripheral blood mononuclear cell pellets were obtained from 1,945 men enrolled in the Multicenter AIDS Cohort. Individuals were genotyped for ancestry informative markers (AIMs) and stratified by biogeographical ancestry (BGA). Then serum levels of total cholesterol (TCHOL), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TRIG) were examined controlling for a number of HIV and HAART-related covariates using multivariate mixed-effects linear regression. HIV-1 infection, in the absence of HAART, was associated with altered lipid levels for all phenotypes tested when compared to HIV-negative men. HIV-1-infected men receiving HAART also had significantly different lipid levels compared to HIV-negative men, except for LDL-C. There were statistically significant interactions between BGA and HIV/HAART status for all lipids tested. BGA remained significantly associated with lipid levels after controlling for other HIV and HAART-related covariates. There was low concordance between self-reported race (SRR) and BGA in admixed populations. BGA performed better than SRR in our statistical models. Lipid profiles in untreated HIV-1-positive men and HIV-1-positive men receiving HAART differ from HIV-negative men and this effect varies by BGA. BGA performed better in our statistical analysis as a racial classifier but SRR remains a good clinical surrogate for BGA.

Nutrition and the HIV-associated lipodystrophy syndrome

HIV-associated lipodystrophy syndrome (HALS), comprising metabolic and morphological alterations, is a known side effect of highly active antiretroviral therapy (HAART). Evidence for the role of nutrition in the management of the systemic parameters of HALS is currently limited. In the present paper we review the current knowledge base surrounding HALS, focusing particularly on the role of nutrition in mitigating the systemic parameters of the syndrome. Reported prevalence of HALS was found to vary from 9 to 83 % due to lack of a standardised definition, as well as variations in assessment methods and in the study population used. HALS is associated with both morphological (lipoatrophy, lipohypertrophy) and metabolic (dyslipidaemia, glucose intolerance, diabetes, hypertension, endothelial dysfunction and atherosclerosis) alterations, which may occur singly or in combination, and are associated with an increased risk of CVD. HAART-induced adipocyte inflammation, oxidative stress and macrophage infiltration, as well as altered adipocyte function and mitochondrial toxicity, have been shown to be central to the development of HALS. The adipocyte, therefore, represents a plausible target for treatment. Pharmacological and surgical treatment interventions have shown effect. However, their use is associated with numerous adverse effects and complications. Targeted lifestyle interventions may provide a useful alternative for managing HALS owing to their safety and tolerability. A Mediterranean-style diet has been found to be effective in improving the systemic parameters of HALS. Furthermore, the effects of n-3 PUFA supplementation are encouraging and future randomised controlled trials investigating the beneficial effects of n-3 PUFA in HALS are justified.

Future directions: lung aging, inflammation, and human immunodeficiency virus

Chronic lung diseases, including chronic obstructive pulmonary disease (COPD) and pulmonary hypertension (PH), are unusually prevalent among persons infected with human immunodeficiency virus (HIV). Often these disease states are identified at younger ages than would be expected in the general population. Recent epidemiologic, basic scientific, and cross-sectional clinical data have implicated immune dysfunction and cellular senescence as potential drivers of advanced presentations of age-related diseases in HIV-infected persons. This article describes how HIV-associated COPD and PH may fit into a paradigm of immunosenescence, and outlines the hypothesized associations among chronic HIV infection, immune dysfunction and senescence, and cardiopulmonary outcomes.

HIV stroke risk: evidence and implications

An estimated 34 million men, women, and children are infected with human immunodeficiency virus type 1 (HIV-1), the virus that causes acquired immunodeficiency syndrome (AIDS). Current technology cannot eradicate HIV-1, and most patients with HIV-1-infection (HIV+) will require lifelong treatment with combined antiretroviral therapy (cART). Stroke was recognized as a complication of HIV-1 infection since the early days of the epidemic. Potential causes of stroke in HIV-1 include opportunistic infections, tumors, atherosclerosis, diabetes, hypertension, autoimmunity, coagulopathies, cardiovascular disease, and direct HIV-1 infection of the arterial wall. Ischemic stroke has emerged as a particularly significant neurological complication of HIV-1 and its treatment due to the aging of the HIV+ population, chronic HIV-1 infection, inflammation, and prolonged exposure to cART. New prevention and treatment strategies tailored to the needs of the HIV+ population are needed to address this issue.

Risk of cardiovascular disease from antiretroviral therapy for HIV: a systematic review

Background

Recent studies suggest certain antiretroviral therapy (ART) drugs are associated with increases in cardiovascular disease.

Purpose

We performed a systematic review and meta-analysis to summarize the available evidence, with the goal of elucidating whether specific ART drugs are associated with an increased risk of myocardial infarction (MI).

Data Sources

We searched Medline, Web of Science, the Cochrane Library, and abstract archives from the Conference on Retroviruses and Opportunistic Infections and International AIDS Society up to June 2011 to identify published articles and abstracts.

Study Selection

Eligible studies were comparative and included MI, strokes, or other cardiovascular events as outcomes.

Data Extraction

Eligibility screening, data extraction, and quality assessment were performed independently by two investigators.

Data Synthesis

Random effects methods and Fisher’s combined probability test were used to summarize evidence.

Findings

Twenty-seven studies met inclusion criteria, with 8 contributing to a formal meta-analysis. Findings based on two observational studies indicated an increase in risk of MI for patients recently exposed (usually defined as within last 6 months) to abacavir (RR 1.92, 95% CI 1.51–2.42) and protease inhibitors (PI) (RR 2.13, 95% CI 1.06–4.28). Our analysis also suggested an increased risk associated with each additional year of exposure to indinavir (RR 1.11, 95% CI 1.05–1.17) and lopinavir (RR 1.22, 95% CI 1.01–1.47). Our findings of increased cardiovascular risk from abacavir and PIs were in contrast to four published meta-analyses based on secondary analyses of randomized controlled trials, which found no increased risk from cardiovascular disease.

Conclusion

Although observational studies implicated specific drugs, the evidence is mixed. Further, meta-analyses of randomized trials did not find increased risk from abacavir and PIs. Our findings that implicate specific ARTs in the observational setting provide sufficient evidence to warrant further investigation of this relationship in studies designed for that purpose.

2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult

Many developments have occurred since the publication of the widely-used 2009 Canadian Cardiovascular Society (CCS) Dyslipidemia guidelines. Here, we present an updated version of the guidelines, incorporating new recommendations based on recent findings and harmonizing CCS guidelines with those from other Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used, per present standards of the CCS. The total cardiovascular disease Framingham Risk Score (FRS), modified for a family history of premature coronary disease, is recommended for risk assessment. Low-density lipoprotein cholesterol remains the primary target of therapy. However, non-high density lipoprotein cholesterol has been added to apolipoprotein B as an alternate target. There is an increased emphasis on treatment of higher risk patients, including those with chronic kidney disease and high risk hypertension. The primary panel has recommended a judicious use of secondary testing for subjects in whom the need for statin therapy is unclear. Expanded information on health behaviours is presented and is the backbone of risk reduction in all subjects. Finally, a systematic approach to statin intolerance is advocated to maximize appropriate use of lipid-lowering therapy. This document presents the recommendations and principal conclusions of this process. Along with associated Supplementary Material that can be accessed online, this document will be part of a program of knowledge translation. The goal is to increase the appropriate use of evidence-based cardiovascular disease event risk assessment in the management of dyslipidemia as a fundamental means of reducing global risk in the Canadian population.

HIV and coronary heart disease: time for a better understanding

Cardiovascular disease, and particularly coronary heart disease, is an emerging area of concern in the HIV population. Since the advent of efficient antiretroviral therapies and the consequent longer patient life span, an increased risk for myocardial infarction has been observed in HIV-infected patients compared with the general population in Western countries. The pathophysiology of this accelerated atherosclerotic process is complex and multifactorial. Traditional cardiovascular risk factors-overrepresented in the HIV population-associated with uncontrolled viral replication and exposure to antiretroviral drugs (per se or through lipid and glucose disturbances) could promote acute ischemic events. Thus, despite successful antiviral therapy, numerous studies suggest a role of chronic inflammation, together with immune activation, that could lead to vascular dysfunction and atherothrombosis. It is time for physicians to prevent coronary heart disease in this high-risk population through the use of tools employed in the general population. Moreover, the lower median age at which acute coronary syndromes occur in HIV-infected patients should shift prevention to include patients <45 years of age. Available cardiovascular risk scores in the general population usually fail to screen young patients at risk for myocardial infarction. Moreover, the novel vascular risk factors identified in HIV-related atherosclerosis, such as chronic inflammation, immune activation, and some antiretroviral agents, are not taken into account in the available risk scores, leading to underestimation of cardiovascular risk in the HIV population. Cardiovascular prevention in HIV-infected patients is a challenge for both cardiologists and physicians involved in HIV care. We require new tools to assess this higher risk and studies to determine whether intensive primary prevention is warranted.

Inflammatory biomarker changes and their correlation with Framingham cardiovascular risk and lipid changes in antiretroviral-naive HIV-infected patients treated for 144 weeks with abacavir/lamivudine/atazanavir with or without ritonavir in ARIES

Propensity for developing coronary heart disease (CHD) is linked with Framingham-defined cardiovascular risk factors and elevated inflammatory biomarkers. Cardiovascular risk and inflammatory biomarkers were evaluated in ARIES, a Phase IIIb/IV clinical trial in which 515 antiretroviral-naive HIV-infected subjects initially received abacavir/lamivudine + atazanavir/ritonavir for 36 weeks. Subjects who were virologically suppressed by week 30 were randomized 1:1 at week 36 to either maintain or discontinue ritonavir for an additional 108 weeks. Framingham 10-year CHD risk scores (FRS) and risk category of <6% or ≥6%, lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), interleukin-6 (IL-6), and high-sensitivity C-reactive protein (hsCRP) were assessed at baseline, week 84, and week 144. Biomarkers were stratified by FRS category. When ritonavir-boosted/nonboosted treatment groups were combined, median hsCRP did not change significantly between baseline (1.6 mg/liter) and week 144 (1.4 mg/liter) in subjects with FRS <6% (p=0.535) or with FRS ≥6% (1.9 mg/liter vs. 2.0 mg/liter, respectively; p=0.102). Median IL-6 was similar for subjects with FRS <6% (p=0.267) at baseline (1.6 pg/ml) and week 144 (1.4 pg/ml) and for FRS ≥6% (2.0 pg/ml vs. 2.2 pg/ml, respectively; p=0.099). Median Lp-PLA(2) decreased significantly (p<0.001) between baseline (197 nmol/min/ml) and week 144 (168 nmol/min/ml) in subjects with FRS <6% and with FRS ≥6% (238 nmol/min/ml vs. 175 nmol/min/ml, respectively; p<0.001). In conclusion, in antiretroviral-naive subjects treated with abacavir-based therapy for 144 weeks, median inflammatory biomarker levels for hsCRP and IL-6 generally remained stable with no significant difference between baseline and week 144 for subjects with either FRS <6% or FRS ≥6%. Lp-PLA(2) median values declined significantly over 144 weeks for subjects in either FRS stratum.

A Study to Evaluate Lipid Profile in Treatment Naïve HIV Positive Patients

HIV infection is associated with lipid abnormalities in treatment naïve patients. CD4 count is used for monitoring the HIV infection. Primary objective was to evaluate and correlate lipid profile and CD4 counts in HIV infection. Secondary objective was to evaluate the feasibility of using Lipid profile to monitor the HIV infected treatment naïve patients instead of CD4 counts. 112 patients were selected based on a criteria from ART center in tertiary care center. CD4 counts were assessed and Lipid profile was evaluated enzymatically. A correlation study was done between the lipid profile and the CD4 count and clinical stages of infection. Cholesterol showed no significant correlation in any stage. HDL-C showed significant correlation (p < 0.05) with stage 2 and 4 disease. LDL-C showed no significant correlation in any stage. TGL showed significant correlation (p < 0.05) at stage 4 disease. Hence, HDL-C and TGL can be used as indicators of lipid status and for infection progression in treatment naive HIV patients, while Cholesterol and LDL-C has no role to play.

Microvascular Endothelial Dysfunction and Enhanced Thromboxane and Endothelial Contractility in Patients with HIV

11 BACKGROUND

The prevalence of cardiovascular disease is increased with human immunodeficiency virus (HIV) infection, but the mechanism is unclear. We hypothesized that HIV increases microvascular reactive oxygen species, thereby impairing endothelial function and enhancing contractility.

12 METHOD

Subcutaneous microarterioles were isolated from gluteal skin biopsies in premenopausal, African American, HIV positive women receiving effective anti-retroviral therapy, but without cardiovascular risk factors except for increased body mass index (n=10) and healthy matched controls (n=10). The arterioles were mounted on myographs, preconstricted and relaxed with acetylcholine for: endothelium-dependent relaxation, endothelium-dependent relaxation factor (nitric oxide synthase-dependent relaxation), endothelium-dependent hyperpolarizing factor (potassium-channel dependent relaxation) and endothelium-independent relaxation (nitroprusside). Contractions were tested to endothelium-dependent contracting factor (acetylcholine contraction with blocked relaxation); phenylephrine, U-46,619 and endothelin-1. Plasma L-arginine and asymmetric dimethylarginine were measured by high performance capillary electrophoresis.

13 RESULTS

The micro-arterioles from HIV positive women had significantly (% change in tension; P<0.05) reduced acetylcholine relaxation (-51 ± 6 vs. -78 ± 3%), endothelium-dependent relaxation factor (-28 ± 4 vs. -39 ± 3%), endothelium-dependent hyperpolarizing factor (-17 ± 4 vs. -37 ± 4%) and decreased nitric oxide activity (0.16 ± 0.03 vs. 0.70 ± 0.16 Δ unit) but unchanged nitroprusside relaxation. They had significantly enhanced endothelium-dependent contracting factor (+21 ± 6 vs. +7 ± 2%) and contractions to U-46,619 (+164 ± 10 vs. +117 ± 11%) and endothelin-1(+151 ± 12 vs. +97 ± 9%), but not to phenylephrine. There was enhanced reactive oxygen species with acetylcholine (0.11 ± 0.02 vs. 0.05 ± 0.01 Δ unit; P<0.05) and endothelin-1 (0.31 ± 0.06 vs. 0.10 ± 0.02 Δ unit; P<0.05). Plasma L-arginine: assymetric dimethyl arginine rates was reduced (173 ± 12 vs. 231 ± 6 μmol·μmol^-1, P<0.05).

14 CONCLUSION

Premenopausal HIV positive womenhad microvascular oxidative stress with severe endothelial dysfunction and reduced nitric oxide and arginine: assymetric dimethylarginine ratio but enhanced endothelial, thromboxane and endothelin contractions. These microvascular changes may herald later cardiovascular disease.

Serum retinol-binding protein-4 levels are increased in HIV-infected subjects with metabolic syndrome receiving highly active antiretroviral therapy

Metabolic syndrome is an important long term complication in chronic asymptomatic HIV-infected subjects under highly active antiretroviral therapy (HAART), because it can contribute to morbidity and mortality via cardiovascular disease (CVD). Therefore, a predictive marker for early detection of metabolic syndrome may be necessary to prevent CVD in HIV-infected subjects. Retinol-binding protein- 4 (RBP-4) has been shown to be associated with metabolic syndrome in various non-HIV-infected populations. We performed a cross-sectional study to evaluate whether serum RBP-4 levels are correlated with metabolic syndrome in HIV-infected subjects receiving HAART. In total, 98 HIV-infected Koreans who had been receiving HAART for at least 6 months were prospectively enrolled. Metabolic syndrome was diagnosed according to the Adult Treatment Panel III criteria, and serum RBP-4 concentrations were measured using human RBP-4 sandwich enzyme- linked immunosorbent assay. Serum RBP-4 levels were significantly higher in HIV-infected subjects receiving HAART with metabolic syndrome (n=33, 33.9±7.7 μg/mL) than in those without it (n=65, 29.9±7.2 μg/mL) (p=0.012). In multivariate linear regression analysis, the number of components of metabolic syndrome presented and waist circumference were independently, significantly correlated with RBP-4 (p=0.018 and 0.030, respectively). In conclusion, we revealed a strong correlation between RBP-4 and the number of components of metabolic syndrome in HIV-infected subjects receiving HAART.

Pathophysiology of the HIV-Associated Lipodystrophy Syndrome

The widespread use of highly active antiretroviral therapy (HAART) has radically transformed the prognosis of HIV-infected patients in the developed countries. Unfortunately, a serious metabolic syndrome combining peripheral lipoatrohy, central adiposity, insulin resistance, and dyslipidemia has arisen in these individuals. The etiology of this heterogeneous syndrome named lipodystrophy syndrome (LDS) is multifactorial, but adipose tissue is very likely a key factor that contributes to several clinical or metabolic aspects of the syndrome. In peripheral adipose tissue, HAART may act on both preadipocytes and adipocytes to induce fat loss. Several components of the HAART regimen can inhibit preadipocyte differentiation, in particular through alterations in the expression and/or function of the transcription factor sterol responsive element binding protein-1c. In superficial mature adipocytes, HAART promotes insulin resistance and apoptosis. Insulin resistance of peripheral fat cells could be the consequence of increased lipolysis and adipocytokine dysregulation. In turn, the increased free fatty acid disposal and the disturbances in adipocytokine production may induce skeletal muscle and liver insulin resistance, dyslipidemia, and a fat redistribution toward deep depots, causing visceral lipohypertrophy. The metabolic profile observed in LDS is reminiscent of that observed in metabolic syndrome, raising potential implications for cardiovascular risk in these patients. The pathophysiological mechanisms at the basis of this syndrome represent a rational basis for the treatment or prevention of the metabolic complications.

HIV infection and stroke: current perspectives and future directions

HIV infection can result in stroke via several mechanisms, including opportunistic infection, vasculopathy, cardioembolism, and coagulopathy. However, the occurrence of stroke and HIV infection might often be coincidental. HIV-associated vasculopathy describes various cerebrovascular changes, including stenosis and aneurysm formation, vasculitis, and accelerated atherosclerosis, and might be caused directly or indirectly by HIV infection, although the mechanisms are controversial. HIV and associated infections contribute to chronic inflammation. Combination antiretroviral therapies (cART) are clearly beneficial, but can be atherogenic and could increase stroke risk. cART can prolong life, increasing the size of the ageing population at risk of stroke. Stroke management and prevention should include identification and treatment of the specific cause of stroke and stroke risk factors, and judicious adjustment of the cART regimen. Epidemiological, clinical, biological, and autopsy studies of risk, the pathogenesis of HIV-associated vasculopathy (particularly of arterial endothelial damage), the long-term effects of cART, and ideal stroke treatment in patients with HIV are needed, as are antiretrovirals that are without vascular risk.

Angina pectoris in patients with HIV/AIDS: prevalence and risk factors

INTRODUCTION

The incidence of ischemic heart disease is higher in patients with HIV/AIDS. However, the frequency of angina pectoris in these patients is still not known. Literature about this subject is still scarce.

OBJECTIVE

To evaluate the prevalence of angina pectoris and risk factors for coronary disease and to examine the association between traditional risk factors and HIV-related risk factors and angina pectoris.

METHOD

An epidemiological cross-sectional study, analyzed as case-control study, involving 584 patients with HIV/AIDS. Angina pectoris was identified by Rose questionnaire, classified as definite or possible. Information regarding risk factors was obtained through a questionnaire, biochemical laboratory tests, medical records and anthropometric measures taken during consultations at AIDS treatment clinics in Pernambuco, Brazil, from June 2007 to February 2008. To adjust the effect of each factor in relation to others, multiple logistic regression was used.

RESULTS

There was a preponderance of men (63.2%); mean ages were 39.8 years for men, 36.8 years for women. The prevalence of definite and possible angina were 11% and 9.4%, respectively, totaling 20.4%, with independent associations between angina and smoking (OR = 2.88; 95% CI: 1.69-4.90), obesity (OR = 1.62; 95% CI: 0.97-2.70), family history of heart attack (OR = 1.70; 95% CI: 1.00-2.88), low schooling (OR = 2.11; 95% CI: 1.24-3.59), and low monthly income (OR = 2.93; 95% CI: 1.18-7.22), even after adjustment for age.

CONCLUSION

This study suggests that angina pectoris is underdiagnosed, even in patients with medical monitoring, revealing lost opportunities in identification and prevention of cardiovascular morbidity.

The glory of guidelines and the twilight of reality: controversies and challenges in the prevention and treatment of HIV in children

Since the discovery of HIV 30 years ago, we have learned much about HIV in children and adolescents. Dramatic declines have occurred in mother-to-child transmission of HIV in resource-rich countries. Resource-poor countries struggle with improving prevention of mother-to-child transmission due to the lack of universal antiretroviral treatment for pregnant and nursing mothers. In children infected with HIV, pharmacokinetic, safety and efficacy data have been determined for many of the older drugs. Data are lacking for the newer, safer and more effective currently available drugs, resulting in the pediatric guidelines lagging behind adult recommendations. Although guidelines for prevention and treatment are helpful, the way they are created causes them to lag behind new scientific evidence, and in some situations they will be confusing or only based on expert opinion. Improving prevention of HIV infection in adolescents and young adults and in treating those who become HIV infected is crucially important. The next 10 years hold tremendous opportunities for improvements in prevention and treatment of HIV in children, adolescents and young adults.

HIV infection and coronary heart disease: an intersection of epidemics

Patients with human immunodeficiency virus (HIV) infection are at increased risk of developing coronary heart disease (CHD). Although factors potentially contributing to this elevated risk include traditional CHD risk factors and antiretroviral medications, more recent data support a role for inflammatory and immunologic factors as central to a complex mechanism. Decreasing CHD risk among HIV-infected patients is likely to involve modification of inflammatory and immunologic factors through antiretroviral therapy or other novel strategies as well as targeted treatment of traditional CHD risk factors. This review will highlight epidemiologic data investigating the association between HIV and CHD outcomes. An overview of potential mechanistic factors associated with CHD in HIV infection and of strategies for managing CHD risk in HIV-infected patients is also included. Specific cardiovascular and metabolic risk factors, CHD risk prediction, and the immunologic basis for CHD in HIV-infected patients will be discussed in separate reviews.

Low free testosterone in HIV-infected men is not associated with subclinical cardiovascular disease

OBJECTIVES

Low testosterone (T) is associated with cardiovascular disease (CVD) and increased mortality in the general population; however, the impact of T on subclinical CVD in HIV disease is unknown. This study examined the relationships among free testosterone (FT), subclinical CVD, and HIV disease.

METHODS

This was a cross-sectional analysis in 322 HIV-uninfected and 534 HIV-infected men in the Multicenter AIDS Cohort Study. Main outcomes were coronary artery calcification presence, defined as a coronary artery calcium (CAC) score  >10 (CAC score was the geometric mean of the Agatston scores of two computed tomography replicates), and far wall common carotid intima-media thickness (IMT)/carotid lesion presence by B-mode ultrasound.

RESULTS

Compared with the HIV-uninfected men in our sample, HIV-infected men were younger, with lower body mass index (BMI) and more often Black. HIV-infected men had lower FT (age-adjusted FT 88.7 ng/dL vs. 101.7 ng/dL in HIV-uninfected men; P=0.0004); however, FT was not associated with CAC, log carotid IMT, or the presence of carotid lesions. HIV status was not associated with CAC presence or log carotid IMT, but was associated with carotid lesion presence (adjusted odds ratio 1.69; 95% confidence interval 1.06, 2.71) in HIV-infected men compared with HIV-uninfected men.

CONCLUSIONS

Compared with HIV-uninfected men, HIV-infected men had lower FT, as well as more prevalent carotid lesions. In both groups, FT was not associated with CAC presence, log carotid IMT, or carotid lesion presence, suggesting that FT does not influence subclinical CVD in this population of men with and at risk for HIV infection.

Human immunodeficiency virus & cardiovascular risk

Highly active antiretroviral therapy (HAART) significantly changed the prevalence of the cardiovascular manifestations of human immunodeficiency virus (HIV)/AIDS. In developed countries, a 30 per cent reduction in the prevalence of cardiomyopathy and pericardial effusion was observed, possibly related to a reduction of opportunistic infections and myocarditis. In developing countries, however, where the availablity of HAART is limited, and the pathogenic impact of nutritional factors is significant, a 32 per cent increase was seen in the prevalence of cardiomyopathy and related high mortality rate from congestive heart failure. Also, some HAART regimens in developed countries, especially those including protease inhibitors, may cause, in a high proportion of HIV-infected patients, a lipodystrophy syndrome that is associated with an increased risk of cardiovascular events related to a process of accelerated atherosclerosis. Careful cardiac screening is warranted for patients who are being evaluated for, or who are receiving HAART regimens, particularly for those with known underlying cardiovascular risk factors, according to the most recent clinical guidelines.

Antiretroviral drugs: critical issues and recent advances

Human immunodeficiency virus (HIV) infection is now recognized as a chronic illness. Although the success of highly active antiretroviral therapy is beyond question, several issues still persist. Since the drugs cannot eradicate the virus, cure is not yet possible, and patients have to maintain a lifelong adherence with the risk of toxic effects, drug-drug interactions and drug resistance. A clear understanding of the viral replication and its interaction with host cell factors has led to the development of a large number of effective antiretroviral drugs (ARVs). New drugs in the existing class such as apricitabine, elvucitabine and etravirine have shown promising results against HIV isolates resistant to first line drugs. These drugs have offered a new choice for patients with drug resistant disease. However, the impact of their long term use on safety is yet to be assessed. Novel drugs with unique mechanism of action such as CD4 receptor attachment inhibitors, maturation inhibitors, pharmacokinetic enhancers, capsid assembly inhibitors and lens epithelium derived growth factor inhibitors are still under development. Currently, ARVs, especially tenofovir and emtricitabine, are also being evaluated for prevention of sexual transmission of HIV-1. The initial results of an HIV prevention trial network are encouraging and have recommended the use of ARVs for pre-exposure prophylaxis. Thus, ARVs form the key component of HIV prevention and treatment strategy. This article discusses the challenges associated with HIV-1 treatment and updates several major advances in the development of ARVs.

Vitamin D deficiency is associated with silent coronary artery disease in cardiovascularly asymptomatic African Americans with HIV infection

BACKGROUND

Growing evidence suggests that vitamin D deficiency Is associated with clinical coronary artery disease (CAD). The relationship between vitamin D deficiency and subclinical CAD in HIV-infected individuals is not well-characterized.

METHODS

Computed tomographic (CT) coronary angiography was performed using contrast-enhanced 64-slice multidetector CT imaging, and vitamin D levels and the presence of traditional and novel risk factor for CAD were obtained in 674 HIV-infected African American (AA) participants aged 25-54 years in Baltimore, MD, without symptoms/clinical evidence of CAD.

RESULTS

The prevalence of vitamin D deficiency (25-hydroxy vitamin D <10 ng/mL) was 20.0% (95% confidence interval [CI], 16.9-23.1). Significant (≥50%) coronary stenosis was present in 64 (9.5%) of 674 participants. Multiple logistic regression analysis revealed that male gender (adjusted odds ratio [OR], 2.19; 95% CI, 1.17-4.10), diastolic BP ≥85 mmHg (adjusted OR: 1.94, 95% CI: 1.02 -3.68), low-density lipoprotein cholesterol ≥100 mg/dL (adjusted OR, 1.95; 95% CI, 1.13-3.36), cocaine use for ≥15 years (adjusted OR, 1.77; 95% CI, 1.01-3.10), use of antiretroviral therapies for ≥6 months (adjusted OR, 2.26; 95% CI, 1.17-4.36), year of enrollment after 2005 (adjusted ORs for 2006-2007, 2008-2009, and 2010 were 0.32 [95% CI, 0.13-0.76], 0.26 [95% CI, 0.12-0.56], and 0.32 (95% CI, 0.15-0.65], respectively), and vitamin D deficiency (adjusted OR, 2.28; 95% CI, 1.23-4.21) were independently associated with significant coronary stenosis.

CONCLUSIONS

Both vitamin D deficiency and silent CAD are prevalent in HIV-infected AAs. In addition to management of traditional CAD risk factors and substance abuse, vitamin D deficiency should be evaluated in HIV-infected AAs. These data support the conduct of a prospective trial of vitamin D in this high-risk patient population.

HIV infection, aging and cardiovascular disease: epidemiology and prevention

In the developed world, HIV infection is now well managed with very effective and less toxic antiretroviral treatment. HIV-positive patients therefore are living longer, but are now faced by challenges associated with aging. Several non-AIDS associated morbidities are increased in this population, including cardiovascular disease (CVD). It is suggested that CVD occurs earlier among HIV-positive patients compared with HIV-negative patients, and at a higher rate. Several factors have been proposed to contribute to this. First, the traditional CVD risk factors are highly prevalent in this population. High rates of smoking, dyslipidaemia and a family history of CVD have been reported. This population is also aging, with estimates of more than 25% of HIV-positive patients in the developed world being over the age of 50. Antiretroviral treatment, both through its effect on lipids and through other, sometimes less well understood, mechanisms, has been linked to increased CVD risk. HIV infection, especially untreated, is a further contributing factor to increased CVD risk in HIV-positive patients. As the HIV-positive population continues to age, the risk of CVD will continue to increase. Guidelines for the management and prevention of CVD risk have been developed, and are largely modelled on those used in the general population. However, the data currently suggest that these interventions, such as the use of lipid-lowering medications and smoking cessation programs, remain quite low. A better understanding the mechanisms of CVD risk in this aging population and further efforts in improving uptake of prevention strategies will remain an important research area.

Recent developments regarding human immunodeficiency virus infection and stroke

Human immunodeficiency virus (HIV) infection is strongly associated with ischemic stroke in the young. Data obtained from the Nationwide Inpatient Sample in the United States show an increase in the number of stroke hospitalizations in the HIV-infected population despite an overall decrease in the number of stroke hospitalizations. Few data exist, however, that address the mechanism of HIV-associated stroke. Recent studies have demonstrated that HIV may infect the endothelium and alter cerebrovascular functions. Whether the proposed mechanism alters the stroke risk is undetermined. Epidemiological studies suggest that HIV-related stroke is associated with a risk factor profile that differs from the HIV-negative young stroke population in that HIV-associated strokes are less likely to have hypertension, diabetes, hyperlipidemia and smoking as risk factors. A large population-based study, moreover, suggests an association between antiretroviral therapy and increased cardio- and cerebrovascular risks. Specific antiretroviral agents such as protease inhibitors and non-nucleoside reverse transcriptase inhibitors have been implicated in the metabolic syndrome, accelerated atherosclerosis and an increased risk for ischemic stroke. In addition to discussing these developments, this paper also discusses the implications of recent data for stroke prevention in HIV-infected patients.

A prospective cohort study of periodontal disease measures and cardiovascular disease markers in HIV-infected adults

The determinants of HIV-associated cardiovascular disease (CVD) are not well understood. Periodontal disease (PD) has been linked to CVD but this connection has not been examined in HIV infection. We followed a cohort of HIV-infected adults to ascertain whether PD was associated with carotid artery intima media thickness (IMT) and brachial artery flow-mediated dilation (FMD). We performed a longitudinal observational study of HIV-infected adults on HAART for <2 years with no known heart disease. PD was characterized clinically and microbiologically. Cardiovascular disease was assessed by IMT/FMD. Linear mixed models assessed cross-sectional and longitudinal associations between PD and FMD/IMT. Forty three HIV(+) adults completed a median of 24 (6-44) months on the study. Defining delta to be the change in a variable between baseline and a follow-up time, longitudinally, on average and after adjusting for change in time, CVD-specific and HIV-specific potential confounding covariates, a 1-log(10) increase in delta Porphyromonas gingivalis was associated with a 0.013 mm increase in delta IMT (95% CI: 0.0006-0.0262; p=0.04). After adjusting for the same potential confounding covariates, a 10% increase in delta gingival recession was associated with a 2.3% increase in delta FMD (95% CI: 0.4-4.2; p=0.03). In a cohort of HIV-infected adults, an increase in subgingival Porphyromonas gingivalis, a known periodontal pathogen, was significantly associated with longitudinal increases in IMT, while increased gingival recession, which herein may represent PD resolution, was significantly associated with longitudinal improvement in FMD. In the context of HIV infection, PD may contribute to CVD risk. Intervention studies treating PD may help clarify this association.

Prevalence and prognostic significance of ECG abnormalities in HIV-infected patients: results from the Strategies for Management of Antiretroviral Therapy study

BACKGROUND

It remains debated whether to include resting electrocardiogram (ECG) in the routine care of human immunodeficiency virus (HIV)-infected patients.

METHODS

This analysis included 4518 HIV-infected patients (28% women and 29% blacks) from the Strategies for Management of Antiretroviral Therapy study, a clinical trial aimed to compare 2 HIV treatment strategies. ECG abnormalities were classified using the Minnesota Code. Cox proportional hazards analysis was used to examine the association between baseline ECG abnormalities and incident cardiovascular disease (CVD).

RESULTS

More than half of the participants (n = 2325, or 51.5%) had either minor or major ECG abnormalities. Minor ECG abnormalities (48.6%) were more common than major ECG abnormalities (7.7%). During a median follow-up of 28.7 months, 155 participants (3.4%) developed incident CVD. After adjusting for the study-treatment arms, the presence of major, minor, and either minor or major ECG abnormalities was significantly predictive of incident CVD (hazard ratio [95% confidence interval]: 2.76 [1.74-4.39], P < .001; 1.58 [1.14-2.20], P = .006; 1.57 [1.14-2.18], P = .006, respectively). However, after adjusting for demographics, CVD risk factors, and HIV characteristics (full model), presence of major ECG abnormalities were still significantly predictive of CVD (1.83 [1.12-2.97], P = .015) but not minor or major abnormalities taken together (1.26 [0.89-1.79], P = .18; 1.25 [0.89-1.76], P = .20, respectively). Individual ECG abnormalities that significantly predicted CVD in the fully adjusted model included major isolated ST-T abnormalities, major prolongation of QT interval, minor isolated ST-T, and minor isolated Q-QS abnormalities.

CONCLUSION

Nearly 1 in 2 of the HIV-infected patients in our study had ECG abnormalities; 1 in 13 had major ECG abnormalities. Presence of ECG abnormalities, especially major ECG abnormalities, was independently predictive of incident CVD. These results suggest that the ECG could provide a convenient risk-screening tool in HIV-infected patients.

Cigarette smoking in the HIV-infected population

As mortality due to AIDS-related causes has decreased with the use of antiretroviral therapy, there has been a rise in deaths related to non-AIDS-defining illnesses. Given the exceedingly high prevalence of cigarette smoking among individuals living with HIV infection, tobacco has been implicated as a major contributor to this paradigm shift. Evidence suggests that smoking-related illnesses, such as cardiovascular disease, respiratory illnesses, and certain malignancies, contribute substantially to morbidity and mortality among HIV-infected persons. In this review, we summarize the adverse health consequences of smoking relevant to HIV-infected individuals and discuss smoking cessation in this unique population, including a discussion of barriers to quitting and a review of studies that have examined smoking cessation interventions.

Abacavir use and risk of acute myocardial infarction and cerebrovascular events in the highly active antiretroviral therapy era

BACKGROUND

Some studies have suggested that exposure to antiretroviral therapy (ART) with abacavir is associated with an increased risk of acute myocardial infarction (AMI).

METHODS

Using the Veterans Health Administration's Clinical Case Registry we calculated the risk of AMI and cerebrovascular events (CVA) associated with the cumulative use of abacavir and other nucleoside combinations. We also evaluated the impact of pre-existing chronic kidney disease on the selection of abacavir versus tenofovir in the last recorded ART regimen, and on highly active antiretroviral therapy-associated AMI and CVA risks.

RESULTS

A total of 19,424 human immunodeficiency virus-infected patients contributed 76,376 patient-years of follow. After adjusting for age, hypercholesterolemia, hypertension, type 2 diabetes, and smoking, the hazard ratio (HR) for each year of abacavir use was 1.18 (95% confidence interval [CI], .92-1.50; P=.191) for AMI and 1.16 (95% CI, .98-1.37; P=.096) for CVA. Abacavir use was more common among patients with prior chronic kidney disease than was tenofovir use (12.46% versus 7.15%; P=.0001), and chronic kidney disease was associated with a significantly higher risk of AMI (HR, 2.41; 95% CI, 1.73-3.36), and CVA (HR, 1.80; 95% CI, 1.44-2.24). Compared with patients who received neither tenofovir nor abacavir, patients who received tenofovir had lower risk of AMI (HR, 0.16; 95% CI, .08-.33; P=.0001) and CVA (HR, 0.22; 95% CI, .15-.32; P=.001). Use of abacavir was associated with lower risk of CVA (HR, 0.60; 95% CI, .45-.79).

CONCLUSIONS

We observed no association between cumulative or current abacavir use and AMI or CVA. Abacavir use was more common than was tenofovir use among patients with prior chronic kidney disease, and chronic kidney disease independently predicted higher rates of AMI and CVA.

Associations of cardiovascular variables and HAART with cognition in middle-aged HIV-infected and uninfected women

Despite the use of highly active anti-retroviral treatment (HAART), cognitive impairment remains prevalent in HIV. Indeed a recent study suggested that in certain instances, stopping HAART was associated with improved cognitive function (Robertson et al. Neurology 74(16):1260-1266 2010). HAART is occasionally associated with cardiovascular pathology and such pathology may be associated with cognitive impairment. To explore these associations, we assessed the relative contributions of cardiovascular variables such as hypertension and atherosclerosis, of HIV and HAART to cognition. The participants were members of the Women's Interagency HIV Study. In the analysis of cross-sectional data using general linear models, we assessed the relationship between each cardiovascular variable and Stroop interference time and symbol digit modalities test while adjusting for age, HIV, education, depression, and race/ethnicity. We also analyzed the association of summary measures of HAART use with cognition. In multivariate models, significance was limited to carotid lesions and carotid intima-medial thickness quintile (CIMT) with Stroop interference time (for carotid lesions, coefficient = 10.5, CI 3.5 to 17.5, p = 0.003, N = 1,130; for CIMT quintile, coefficient = 8.6, CI = 1.7 to 15.4, p = 0.025, N = 1,130). The summary measures of protease inhibitor use and other HAART measures were in most cases not associated with cognitive score in multivariate models. We conclude that in the HAART era among middle-aged women with HIV, carotid disease may be significantly associated with some measures of cognitive impairment. In this cross-sectional study, we could detect neither positive nor negative effects of HAART on cognition.

Dyslipidemia in HIV-infected individuals

Metabolic complications continue to play a major role in the management of HIV infection. Dyslipidemia associated with HIV infection and with the use of combined antiretroviral therapy includes elevations in triglycerides, reduced high-density cholesterol, and variable increases in low-density and total cholesterol. The association between dyslipidemia and specific antiretroviral agents has been underscored. Multiple pathogenic mechanisms by which HIV and antiretroviral agents lead to dyslipidemia have been hypothesized, but they are still controversial. The potential clinical and pathological consequences of HIV-associated hyperlipidemia are not completely known, but several studies reported an increased risk of coronary artery disease in HIV-positive individuals receiving combined antiretroviral therapy. HIV-infected persons who have hyperlipidemia should be managed similarly to those without HIV infection in accordance with the National Cholesterol Education Program. Life style changes are the primary target. Statins and fibrates and/or modification in antiretroviral therapy are possible approaches to this problem.

Cardiovascular disease in HIV infection

PURPOSE OF REVIEW

Highly active antiretroviral therapy (HAART) use has markedly reduced AIDS-related mortality and opportunistic illness. With improved survival, cardiovascular disease (CVD) has emerged as an important noninfectious chronic comorbidity among antiretroviral (ARV)-treated HIV-infected persons.

RECENT FINDINGS

HIV infection can impact CVD and comorbidities known to increase CVD risk. Untreated HIV can cause proatherogenic elevations in serum lipids. Chronic HIV viremia results in increases in systemic inflammation, hypercoagulation, and reductions in endovascular reactivity, all of which are at least partially reversible with virally suppressive HAART. Chronic T-cell activation can also result in adverse vascular effects. Use of some ARV drugs can impact CVD risk by causing pro-atherogenic serum lipid elevations, induction of insulin resistance, increases in visceral adiposity or subcutaneous fat loss. Abacavir use may increase myocardial infarction risk by reducing vascular reactivity and/or increasing platelet activation. Traditional risk factors such as advancing age, smoking, hyperlipidemia, and hypertension remain important predictors of CVD among HAART-treated HIV-infected persons.

SUMMARY

HIV in the HAART era is a chronic manageable condition. CVD is an important cause of morbidity among HIV-infected persons. Untreated HIV can increase CVD risk in several ways and these effects are at least partially reversible with successful treatment. Use of specific ARVs can adversely impact CVD risk but the multiple long-term benefits of chronic HIV suppression and immune reconstitution achievable with potent HAART outweigh the adverse impact upon CVD risks that they may have. Standard CVD screening and risk-reducing interventions should be routinely undertaken for HIV-infected persons.

Cardiovascular risk factors in adult Malawians on long-term antiretroviral therapy

Around 225,000 patients currently receive antiretroviral therapy (ART) in the Malawi scale-up programme that uses the public health approach to ART. There are concerns that cardiovascular disease risk factors are common in ART patients, but few data exist from sub-Saharan Africa, and none from Malawi. We did a cross-sectional study of cardiovascular risk factors in urban, adult, Malawian ART patients, with the WHO STEP-wise surveillance tool. We enrolled 174 long-term (>1 year) ART patients during routine clinic visits, mean age 40.8 years (range 18-69), 61.5% female, 97.1% on first-line regimens, median duration ART 35.5 months. Insufficient fruit and vegetable diet (67.6%), raised blood pressure (45.9%), increased waist-hip ratio (45.4%), raised total cholesterol levels (31.0%) and low physical activity level (27.0%) were common, while current smoking (0.6%), current alcohol consumption (2.3%) and elevated glucose levels (1.2%) were rare. In multivariable analyses, higher age was associated with low physical activity, raised blood pressure, being overweight, and increased waist-hip ratio. Longer duration of ART was not associated with any risk factor and was protective for being overweight. Cardiovascular risk factors were common among long-term ART patients in Malawi. This requires more attention and further study in programmes using the public health approach to ART.

Arterial thrombosis in patients with human immunodeficiency virus: two-case reports and review of the literature

Thrombosis during HIV infection was commonly vein thrombosis. Arterial thrombosis is also more and more described. We report two cases detected in the Abidjan Cardiology Institute. Case Reports. Case 1: an HIV infected female presented with sudden loss of consciousness and right hemiplegia. She had been taking HAART regimen for five years. Neck vessels ultrasonography revealed thrombosis on left ICA. Anticoagulant treatment leads to reduction of symptoms and left ICA partial recanalization. Case 2: male HIV infected taking HAART therapy was admitted for an acute pain of left lower limb; examination showed a decrease of heat, sensitivity, and mobility of this limb with popliteal and tibial pulses abolished. Arterial ultrasonography and CT angiography showed occlusion on the lower third of superficial femoral artery and homolateral popliteal artery suggesting a thrombosis of this artery. He underwent a femorotibial bypass surgery and anticoagulant treatment. The outcome was good with reappearance of local heat of the limb and tibial pulses. Probable etiology is early carotid atherosclerosis associated with protein S deficiency in the first case and antiphospholipid syndrome in the second case. Conclusion. Arterial thrombosis might occur in HIV infection. Several etiological factors could be involved in the pathogeny of these arterial thromboses.

A comparison of treatment eligibility for hepatitis C virus in HCV-monoinfected versus HCV/HIV-coinfected persons in electronically retrieved cohort of HCV-infected veterans

Treatment rates for hepatitis C virus (HCV) are low in actual clinical settings. However, the proportion of patients eligible for treatment, especially among those coinfected with HIV, is not well known. Our aim was to determine and compare the rates for HCV treatment eligibility among HCV and HCV-HIV-coinfected persons. We assembled a national cohort of HCV-infected veterans in care from 1998-2003, using the VA National Patient Care Database for demographic/clinical information, the Pharmacy Benefits Management database for pharmacy records, and the Decision Support Systems database for laboratory data. We compared the HCV-monoinfected and HCV-HIV-coinfected subjects for treatment indications and eligibility using current treatment guidelines. Of the 27,452 subjects with HCV and 1225 with HCV-HIV coinfection, 74.0% and 84.6% had indications for therapy and among these, 43.9% of HCV-monoinfected and 28.4% of HCV-HIV-coinfected subjects were eligible for treatment. Anemia, decompensated liver disease (DLD), chronic obstructive pulmonary disease (COPD), recent alcohol abuse, and coronary artery disease were the most common contraindications in the HCV, and anemia, DLD, renal failure, recent drug abuse, and COPD in the HCV-HIV-coinfected group. Among those eligible for treatment, only 23% of the HCV-monoinfected and 15% of the HCV-HIV-coinfected subjects received any treatment for HCV. Most veterans with HCV are not eligible for treatment according to the current guidelines. Even for those who are eligible for treatment, only a minority is prescribed treatment. Several contraindications are modifiable and aggressive management of those may improve treatment prescription rates.

Hypertension is common among HIV-infected persons, but not associated with HAART

BACKGROUND

With improved survival after the introduction of highly active antiretroviral therapy (HAART), non-AIDS-related morbidity and mortality have come to the forefront in the management of HIV patients. HAART has been linked to the development of several risk factors for cardiovascular disease including insulin resistance and hyperlipidemia, but its influence on hypertension requires further study.

METHODS

We performed a cross-sectional study of HIV-infected persons at two large HIV clinics to evaluate the prevalence and factors associated with hypertension. Hypertension was defined by at least two blood pressure measurements >140/90 mmHg or the use of an antihypertensive medication. Statistical analyses included multivariate logistic regression models.

RESULTS

We studied 707 HIV-infected adults with a median age of 41 years (IQR 36-46), 92% were male, 49% were Caucasian, and 72% were receiving HAART. The overall prevalence of hypertension was 31% and was similar among those receiving and not receiving HAART (32% vs. 29%, p = 0.47). Factors associated with hypertension in the multivariate model included increasing age, longer duration of HIV, higher body mass index, and diabetes, with a trend for African American ethnicity.

CONCLUSIONS

Hypertension is common among HIV-infected persons and is associated with established risk factors, but not with HAART use. Given the high prevalence of hypertension and its association with duration of HIV infection, other factors such as virally-mediated endothelial changes or immune activation may play a role. Further investigations are needed.

Risk of cerebrovascular events in persons with and without HIV: a Danish nationwide population-based cohort study

OBJECTIVE

To assess the risk of cerebrovascular events (CVEs) in HIV-infected individuals and evaluate the impact of proven risk factors, injection drug abuse (IDU), immunodeficiency, HAART and family-related risk factors.

DESIGN

Nationwide, population-based cohort study.

METHODS

The study population included all Danish HIV-infected individuals, a population-based comparison cohort and parents of both cohorts - all with no prior cerebral comorbidity. We computed incidence rate ratios (IRRs) of overall CVEs and CVEs with and without proven risk factors, stratifying the analyses on IDU. Impact of immunodeficiency, HAART, protease inhibitors, indinavir, didanosin, tenofovir and abacavir on risk of CVEs was analyzed using time-dependent Cox regression analyses.

RESULTS

HIV-infected individuals had an increased risk of CVEs compared with the comparison cohorts [(non-IDU HIV adjusted IRR 1.60; 95% confidence interval [CI] 1.32-1.94), (IDU HIV adjusted IRR 3.94; 95% CI 2.16-7.16)]. The risk was increased with and without proven risk factors. A CD4 cell count of 200 cells/μl or less before the start of HAART and exposure to abacavir increased the risk of CVE [(adjusted IRR 2.26; 95% CI 1.05-4.86) and (adjusted IRR 1.66; 95% CI 1.03-2.68)]. Protease inhibitors, indinavir, didanosin, tenofovir and HAART in general had no impact. Risk of CVEs was only increased in the parents of IDU HIV-infected individuals.

CONCLUSION

HIV-infected individuals have an increased risk of CVEs with and without proven risk factors. The risk is associated with IDU, low CD4 cell count and exposure to abacavir, but not with HAART. An association with family-related risk factors seems vague except for parents of IDU individuals.