The Opioid Epidemic: Impact on Inflammation and Cardiovascular Disease Risk in HIV

A Perfect Storm: The Convergence of Aging, Human Immunodeficiency Virus Infection, and Inflammasome Dysregulation

The emergence of combination antiretroviral therapy (cART) has greatly transformed the life expectancy of people living with HIV (PWH). Today, over 76% of the individuals with HIV have access to this life-saving therapy. However, this progress has come with a new challenge: an increase in age-related non-AIDS conditions among patients with HIV. These conditions manifest earlier in PWH than in uninfected individuals, accelerating the aging process. Like PWH, the uninfected aging population experiences immunosenescence marked by an increased proinflammatory environment. This phenomenon is linked to chronic inflammation, driven in part by cellular structures called inflammasomes. Inflammatory signaling pathways activated by HIV-1 infection play a key role in inflammasome formation, suggesting a crucial link between HIV and a chronic inflammatory state. This review outlines the inflammatory processes triggered by HIV-1 infection and aging, with a focus on the inflammasomes. This review also explores current research regarding inflammasomes and potential strategies for targeting inflammasomes to mitigate inflammation. Further research on inflammasome signaling presents a unique opportunity to develop targeted interventions and innovative therapeutic modalities for combating HIV and aging-associated inflammatory processes.

Changes in atherosclerotic cardiovascular disease risk over time among people living with HIV

OBJECTIVE

To describe changes in atherosclerotic cardiovascular disease (ASCVD) risk over time among people living with HIV (PLHIV).

METHODS

We used data from the TREAT Asia HIV Observational Database (TAHOD) and the Australian HIV Observational Database (AHOD). Five-year ASCVD risk was calculated using the D:A:D equation. Individuals were eligible for inclusion if they were aged ≥18 years, had started ART, had no previous history of ASCVD and had complete ASCVD risk factor data available within the first 5 years of ART initiation.

RESULTS

A total of 3368 adults contributed data, 3221 were from TAHOD and 147 were from AHOD. The median age at ART initiation was 36 [IQR 31-43] years for TAHOD participants, and 42 [IQR 35-50] years for AHOD participants. Most TAHOD (70.4%) and AHOD (91.8%) participants were male. Overall, ASCVD risk increased from 0.84% (95% CI 0.81%-0.87%) at ART initiation to 1.34% (95% CI 1.29%-1.39%) after 5 years on ART. After adjusting for traditional and HIV-associated ASCVD risk factors, ASCVD risk increased at a similar rate among sub-populations defined by HIV exposure (heterosexuals, men who have sex with men, people who inject drugs), race/ethnicity (Caucasian and Asian) and nadir CD4 at ART initiation (<200 and ≥200 cells/mm3).

CONCLUSIONS

These findings emphasize the growing burden of ASCVD risk among PLHIV and the need to develop interventions that are effective across a broad range of HIV sub-populations.

Pharmacological and Behavioral Interventions to Mitigate Premature Aging in Patients with HIV

PURPOSE OF REVIEW

We sought to review pharmacological and behavioral interventions that have been publicly presented, published, or are currently ongoing to prevent or mitigate the effect of premature HIV-associated comorbidities.

RECENT FINDINGS

Multiple studies have been conducted in hopes of finding an effective intervention. While the choice of antiretroviral regimen influences recovery of immune function, several drugs used as adjunct treatments have proven effective to mitigate premature aging. Additionally, few behavioral interventions have exhibited some efficacy. Statins, angiotensin-receptor blockers, and anti-hyperglycemic agents as well as optimal adherence, exercise, and intermittent fasting among others have had beneficial impact on markers of immune activation and levels of inflammatory biomarkers. However, several investigations had inconclusive outcomes so further studies with larger sample sizes are warranted.

HIV and Drug Use: A Tale of Synergy in Pulmonary Vascular Disease Development

Over the past two decades, with the advent and adoption of highly active anti-retroviral therapy, HIV-1 infection, a once fatal and acute illness, has transformed into a chronic disease with people living with HIV (PWH) experiencing increased rates of cardio-pulmonary vascular diseases including life-threatening pulmonary hypertension. Moreover, the chronic consequences of tobacco, alcohol, and drug use are increasingly seen in older PWH. Drug use, specifically, can have pathologic effects on the cardiovascular health of these individuals. The "double hit" of drug use and HIV may increase the risk of HIV-associated pulmonary arterial hypertension (HIV-PAH) and potentiate right heart failure in this population. This article explores the epidemiology and pathophysiology of PAH associated with HIV and recreational drug use and describes the proposed mechanisms by which HIV and drug use, together, can cause pulmonary vascular remodeling and cardiopulmonary hemodynamic compromise. In addition to detailing the proposed cellular and signaling pathways involved in the development of PAH, this article proposes areas ripe for future research, including the influence of gut dysbiosis and cellular senescence on the pathobiology of HIV-PAH. © 2023 American Physiological Society. Compr Physiol 13:4659-4683, 2023.

Development of Frail RISC-HIV: a Risk Score for Predicting Frailty Risk in the Short-term for Care of People with HIV

OBJECTIVE

Frailty is common among people with HIV (PWH), so we developed frail risk in the short-term for care (RISC)-HIV, a frailty prediction risk score for HIV clinical decision-making.

DESIGN

We followed PWH for up to 2 years to identify short-term predictors of becoming frail.

METHODS

We predicted frailty risk among PWH at seven HIV clinics across the United States. A modified self-reported Fried Phenotype captured frailty, including fatigue, weight loss, inactivity, and poor mobility. PWH without frailty were separated into training and validation sets and followed until becoming frail or 2 years. Bayesian Model Averaging (BMA) and five-fold-cross-validation Lasso regression selected predictors of frailty. Predictors were selected by BMA if they had a greater than 45% probability of being in the best model and by Lasso if they minimized mean squared error. We included age, sex, and variables selected by both BMA and Lasso in Frail RISC-HIV by associating incident frailty with each selected variable in Cox models. Frail RISC-HIV performance was assessed in the validation set by Harrell's C and lift plots.

RESULTS

Among 3170 PWH (training set), 7% developed frailty, whereas among 1510 PWH (validation set), 12% developed frailty. BMA and Lasso selected baseline frailty score, prescribed antidepressants, prescribed antiretroviral therapy, depressive symptomology, and current marijuana and illicit opioid use. Discrimination was acceptable in the validation set, with Harrell's C of 0.76 (95% confidence interval: 0.73-0.79) and sensitivity of 80% and specificity of 61% at a 5% frailty risk cutoff.

CONCLUSIONS

Frail RISC-HIV is a simple, easily implemented tool to assist in classifying PWH at risk for frailty in clinics.

Outcomes of Patients with Opioid-Related Diagnoses in Acute Coronary Syndrome: a National Inpatient Sample-Based Analysis

BACKGROUND

Acute coronary syndrome (ACS) and opioid use are both major causes of morbidity and mortality globally. Although epidemiological studies point to increased risk of ACS in opioid users, in-hospital management and outcomes are unknown for this population when presenting with ACS. We sought to determine whether there are differences for in-hospital outcomes and management of ACS for those with and without opioid-related diagnoses (ORD).

METHODS AND RESULTS

From the National Inpatient Sample database, we extracted patients hospitalized between 2012 and 2016 for ACS. The primary independent variable was ORD by International Classification of Diseases, 9th and 10th Revision, codes. The primary outcome was in-hospital mortality; secondary outcomes were cardiac arrest, receipt of angiogram, and percutaneous coronary intervention (PCI). Statistical comparisons were performed using χ2 test and Student's t test. Multivariable logistic regression was performed to determine the independent association between ORD and outcomes of interest. Among the estimated 5.8 million admissions for ACS, the proportion of patients with ORD increased over the study period (p for trend < 0.01). Compared to patients without ORD presenting with ACS, patients with ORD were younger with fewer cardiovascular risk factors. Yet, in-hospital mortality was higher in patients with ORD presenting with ACS (AOR 1.36, 95% CI 1.26-1.48). Patients with ORD were more likely to experience in-hospital cardiac arrest (AOR 1.42, 95% CI 1.23-1.63) and less likely to undergo angiogram (AOR 0.42, 95% CI 0.38-0.45) or PCI (AOR 0.30, 95% CI 0.28-0.32).

CONCLUSION

Despite evidence of increased risk of mortality and cardiac arrest, patients with ORD admitted for ACS are less likely to receive ACS management.

Disability-adjusted life years associated with chronic comorbidities among people living with and without HIV: Estimating health burden in British Columbia, Canada

Life span of people living with HIV (PLWH) has increased dramatically with the advent of modern antiretroviral therapy. As a result, comorbidities have emerged as a significant concern in this population. To describe the burden of chronic comorbidities among PLWH and HIV-negative individuals in British Columbia (BC), Canada, we estimated disability-adjusted life years (DALYs) related to these comorbidities. Based on a population-based cohort in BC, antiretroviral-treated adult PLWH and 1:4 age-sex-matched HIV-negative controls were followed for ≥1 year during 2001-2012. DALYs combined years of life lost to premature mortality (YLLs) and due to disability (YLDs), and were estimated following the Global Burden of Diseases' approaches. DALYs associated with non-AIDS-defining cancers, diabetes, osteoarthritis, hypertension, dementia, cardiovascular (CVD), kidney, liver and chronic obstructive pulmonary diseases were each measured for 2008-2012. Among PLWH, DALYs attributed to non-AIDS-related cancers were also estimated for 2013-2020. We observed that at baseline, our matched cohort consisted of 82% males with a median age of 40 years (25th-75th percentiles: 34-47). During 2008-2012, 7042 PLWH and 30,640 HIV-negative individuals were alive, where PLWH experienced a twofold higher DALYs associated with chronic comorbidities (770.2 years/1000 people [95% credible intervals: 710.2, 831.6] vs. 359.0 [336.0, 382.2]). Non-AIDS-defining cancers and CVD contributed the highest DALYs in both populations, driven by YLLs rather than YLDs. Among PLWH, we estimated increasing DALYs attributable to non-AIDS-defining cancers with 91.7 years/1000 people (77.4, 106.0) in 2013 vs. 97.6 (81.0, 115.2) in 2020. In this study, we showed that PLWH experience a disproportionate burden of chronic comorbidities compared to HIV-negative individuals. The observed disparities may relate to differential health behaviors, residual HIV-related inflammation, and ART-related toxicities. As aging shapes future healthcare needs, our findings highlight the need to enhance prevention and management of comorbidities as part of HIV care.

A Systematic Review of Opioid Use Disorder and Related Biomarkers

The objective of this systematic review is to examine the relationship between opioid use disorder (OUD) and its related biomarkers, as well as the effects of pharmacotherapy for OUD on biomarkers. The eligibility criteria are the inclusion of human population studies focusing on biomarkers, including the immune system, related to OUD or opioid-related disorders. English, peer reviewed, original research, case studies or case series, and clinical trials were included in this review. Papers were excluded if they met one or more of the following criteria: animal studies, review articles, studies focusing only on OUD or opioid-related disorders without mention of potential biomarkers, studies focusing only on biomarkers and/or the immune system without relating to OUD or opioid-related disorders, and studies that focused on other substance use disorders other than OUD specifically. A PubMed, PsycINFO, and Cochrane databases search on August 25, 2020, yielded 101 results; only 14 articles met inclusion criteria that were included in this review. However, heterogeneity of study definitions and measurements should be noted. Various potential biomarkers indicated systemic, peripheral, and chronic inflammation in patients with OUD or opioid-related disorders. Medications, including buprenorphine and methadone, significantly decreased chronic inflammation in this population. Our results suggest that patients with OUD or opioid-related disorders have potential biomarkers that can be targeted to provide optimal treatment options for this population. A better understanding of potential biomarkers may assist to identify at-risk populations, monitor disease progression and treatment response, and develop therapeutic strategies for OUD. Systematic Review Registration: This review has been registered in PROSPERO (CRD42020202014).

Contribution of Behavioral Health Factors to Non-AIDS-Related Comorbidities: an Updated Review

PURPOSE OF REVIEW

We summarize recent literature on the contribution of substance use and depression to non-AIDS-related comorbidities. Discussion of recent randomized clinical trials and implementation research to curtail risk attributed to each behavioral health issue is provided.

RECENT FINDINGS

Smoking, unhealthy alcohol use, opioid use, and depression are common among PWH and individually contribute to increased risk for non-AIDS-related comorbidities. The concurrence of these conditions is notable, yet understudied, and provides opportunity for linked-screening and potential treatment of more than one behavioral health factor. Current results from randomized clinical trials are inconsistent. Investigating interventions to reduce the impact of these behavioral health conditions with a focus on implementation into clinical care is important. Non-AIDS-defining cancers, cardiovascular disease, liver disease, and diabetes are leading causes of morbidity in people with HIV. Behavioral health factors including substance use and mental health issues, often co-occurring, likely contribute to the excess risk of non-AIDS-related comorbidities.

High prevalence of albuminuria amongst people who inject drugs: A cross-sectional study

Albuminuria is a key biomarker for cardiovascular disease and chronic kidney disease. Our study aimed to describe the prevalence of albuminuria amongst people who inject drugs in London and to test any potential associations with demographic characteristics, past diagnoses, and drug preparation and administration practices. We carried out a cross-sectional survey amongst people who use drugs in London. The main outcome measure was any albuminuria including both microalbuminuria and macroalbuminuria. Three-hundred and sixteen samples were tested by local laboratory services. Our study initially employed point-of-care testing methods but this resulted in a high number of false positives. Our findings suggest the prevalence of albuminuria amongst PWID is twice that of the general population at 19% (95%CI 15.3–24.0%). Risk factors associated with albuminuria were HIV (aOR 4.11 [95% CI 1.37–12.38]); followed by overuse of acidifier for dissolving brown heroin prior to injection (aOR 2.10 [95% CI 1.04–4.22]). Albuminuria is high amongst people who inject drugs compared to the general population suggesting the presence of increased cardiovascular and renal pathologies. This is the first study to demonstrate an association with acidifier overuse. Dehydration may be common amongst this population and may affect the diagnostic accuracy of point-of-care testing for albuminuria.

Differences in receipt of opioid agonist treatment and time to enter treatment for opioid use disorder among specialty addiction programs in the United States, 2014-17

Background

Access to adequate treatment for opioid use disorder (OUD) has been a high priority among American policymakers. Elucidation of the sociodemographic and institutional differences associated with the use, or lack thereof, of opioid agonist therapy (OAT) provides greater clarity on who receives OAT. Timely access to care is a further consideration and bears scrutiny as well.

Methods

We draw upon data from the Treatment Episode Data Set—Admissions (TEDS-A) to analyse the relationship between sociodemographic and institutional characteristics and the receipt of opioid agonist treatments and time waiting to enter treatment.

Results

Estimates from logistic regression models highlight certain groups which show lower odds of receipt of OAT, including those in precarious housing arrangements, those unemployed or not otherwise in the labor force, and those referred by drug abuse care providers, educational institutions, employers, and the criminal justice system. Groups which showed higher odds of waiting over a week to enter treatment included those who were separated, divorced, or widowed, those working part-time, and those referred by drug abuse care providers, employers, and the criminal justice system.

Conclusion

Given the efficacy of OAT and the adverse outcomes associated with long waiting times, coordinated effort is needed to understand why these differences persist and how they may be addressed through appropriate policy responses.