Cardiovascular disease in HIV infection

Comparison of Switching Between Antiretroviral Agents Versus Introducing Lipid-lowering Agents for HAART-induced Dyslipidemia

PURPOSE

Highly active antiretroviral therapy (HAART) has brought a significant reduction in HIV/AIDS-related morbidity and mortality. However, metabolic abnormalities (eg, dyslipidemias) have continued to pose significant challenges, warranting a switch between antiretroviral agents and/or the introduction of a statin. Hence, the purposes of this study was to compare the efficacy of switching between antiretroviral agents versus introducing a statin in the long-term management of HAART-induced dyslipidemia in people living with HIV, and to identify the most potent agent in switching therapies.

METHODS

A comprehensive literature search of PubMed and Medline identified articles published from the years 2000 to 2020 in the English language, resulting in 84 articles, 30 of which were selected based on inclusion and exclusion criteria. Information on primary and secondary outcomes was extracted. Statistical analysis was done on the variables, and the differences between groups were considered significant at P < 0.05.

FINDINGS

Statin use was associated with significant reductions in triglycerides and total cholesterol (TC) at 6 weeks (both, P < 0.01). A switch of antiretroviral agents was associated with gradual reductions in TC and triglycerides for up to 48 weeks (both, P < 0.01). Statin use was associated with a reduced CD4 count at 24 weeks (P < 0.01). A switch of antiretroviral agents was associated with an increased CD4 count at 48 weeks (P < 0.01).

IMPLICATIONS

Statins were as effective as switching antiretroviral therapies in the short-term management of TC and triglycerides in patients with HAART-induced dyslipidemia.

Polygenic Scores and Preclinical Cardiovascular Disease in Individuals With HIV: Insights From the REPRIEVE Trial

BACKGROUND

Coronary artery disease (CAD) is a leading cause of death among the 38.4 million people with HIV globally. The extent to which cardiovascular polygenic risk scores (PRSs) derived in non-HIV populations generalize to people with HIV is not well understood.

METHODS AND RESULTS

PRSs for CAD (GPSMult) and lipid traits were calculated in a global cohort of people with HIV treated with antiretroviral therapy with low-to-moderate atherosclerotic cardiovascular disease risk enrolled in REPRIEVE (Randomized Trial to Prevent Vascular Events in HIV). The PRSs were associated with baseline lipid traits in 4495 genotyped participants, and with subclinical CAD in a subset of 662 who underwent coronary computed tomography angiography. Among participants who underwent coronary computed tomography angiography (mean age, 50.9 [SD, 5.8] years; 16.1% women; 41.8% African, 57.3% European, 1.1% Asian), GPSMult was associated with plaque presence with odds ratio (OR) per SD in GPSMult of 1.42 (95% CI, 1.20-1.68; P=3.8×10-5), stenosis >50% (OR, 2.39 [95% CI, 1.48-3.85]; P=3.4×10-4), and noncalcified/vulnerable plaque (OR, 1.45 [95% CI, 1.23-1.72]; P=9.6×10-6). Effects were consistent in subgroups of age, sex, 10-year atherosclerotic cardiovascular disease risk, ancestry, and CD4 count. Adding GPSMult to established risk factors increased the C-statistic for predicting plaque presence from 0.718 to 0.734 (P=0.02). Furthermore, a PRS for low-density lipoprotein cholesterol was associated with plaque presence with OR of 1.21 (95% CI, 1.01-1.44; P=0.04), and partially calcified plaque with OR of 1.21 (95% CI, 1.01-1.45; P=0.04) per SD.

CONCLUSIONS

Among people with HIV treated with antiretroviral therapy without documented atherosclerotic cardiovascular disease and at low-to-moderate calculated risk in REPRIEVE, an externally developed CAD PRS was predictive of subclinical atherosclerosis. PRS for low-density lipoprotein cholesterol was also associated with subclinical atherosclerosis, supporting a role for low-density lipoprotein cholesterol in HIV-associated CAD.

REGISTRATION

URL: https://www.reprievetrial.org; Unique identifier: NCT02344290.

Receipt of Smoking Cessation Medications Among People With and Without Human Immunodeficiency Virus in the Veterans Aging Cohort Study (2003-2018)

Background

Nicotine replacement therapy, bupropion, and varenicline are smoking cessation medications (SCMs) shown to be similarly effective in people with and without human immunodeficiency virus (PWH and PWoH, respectively), although rates of receipt of these medications are unknown.

Methods

We identified patients in the Veterans Aging Cohort Study with electronic health record-documented current smoking using clinical reminder data for tobacco use (2003-2018). We measured receipt of SCMs using Veterans Affairs pharmacy data for outpatient prescriptions filled 0-365 days after current smoking documentation. We used log-linear, Poisson-modified regression models to evaluate the relative risk (RR) for receiving SCM by human immunodeficiency virus (HIV) status, the annual rate of receipt, and rate difference among PWH relative to PWoH.

Results

The sample included 92 632 patients (29 086 PWH), reflecting 381 637 documentations of current smoking. From 2003 to 2018, the proportion receiving SCMs increased from 15% to 34% for PWH and from 17% to 32% among PWoH. There was no statistical difference in likelihood of receiving SCM by HIV status (RR, 1.010; 95% confidence interval [CI], .994-1.026). Annual rates of receiving SCM increased for PWH by 4.3% per year (RR, 1.043; 95% CI, 1.040-1.047) and for PWoH by 3.7% per year (RR, 1.037; 95% CI, 1.036-1.038; rate difference +0.6% [RR, 1.006; 95% CI, 1.004-1.009]).

Conclusions

In a national sample of current smokers, receipt of SCM doubled over the 16-year period, and differences by HIV status were modest. However, fewer than 35% of current smokers receive SCM annually. Efforts to improve SCM receipt should continue for both groups given the known dangers of smoking.

Using the biomarker cotinine and survey self-report to validate smoking data from United States Veterans Health Administration electronic health records

OBJECTIVE

Tobacco use/smoking for epidemiologic studies is often derived from electronic health record (EHR) data, which may be inaccurate. We previously compared smoking from the United States Veterans Health Administration (VHA) EHR clinical reminder data with survey data and found excellent agreement. However, the smoking clinical reminder items changed October 1, 2018. We sought to use the biomarker salivary cotinine (cotinine ≥30) to validate current smoking from multiple sources.

MATERIALS AND METHODS

We included 323 Veterans Aging Cohort Study participants with cotinine, clinical reminder, and self-administered survey smoking data from October 1, 2018 to September 30, 2019. We included International Classification of Disease (ICD)-10 codes F17.21 and Z72.0. Operating characteristics and kappa statistics were calculated.

RESULTS

Participants were mostly male (96%), African American (75%) and mean age was 63 years. Of those identified as currently smoking based on cotinine, 86%, 85%, and 51% were identified as currently smoking based on clinical reminder, survey, and ICD-10 codes, respectively. Of those identified as not currently smoking based on cotinine, 95%, 97%, and 97% were identified as not currently smoking based on clinical reminder, survey, and ICD-10 codes. Agreement with cotinine was substantial for clinical reminder (kappa = .81) and survey (kappa = .83), but only moderate for ICD-10 (kappa = .50).

DISCUSSION

To determine current smoking, clinical reminder, and survey agreed well with cotinine, whereas ICD-10 codes did not. Clinical reminders could be used in other health systems to capture more accurate smoking information.

CONCLUSIONS

Clinical reminders are an excellent source for self-reported smoking status and are readily available in the VHA EHR.

Biomarkers and Prevalence of Cardiometabolic Syndrome Among People Living With HIV/AIDS, Addis Ababa, Ethiopia: A Hospital-Based Study

BACKGROUND

While the fast extension of combination antiretroviral therapy (cART) has resulted in significant increases in life expectancy, disorders such as cardiometabolic syndrome (CMetS), which have received less attention, are becoming a major concern in HIV/AIDS patients (PLWHA).

OBJECTIVES

The purpose of this research was to identify biomarkers and determine the prevalence of CMetS in PLWHA using the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) tools.

METHODS

Between January 2019 and February 2021, a hospital-based study of HIV-infected patients (n = 288) was conducted. The data were analyzed using binary logistic regression. To control the effect of confounders, independent variables with a P-value of <.20 in the bivariate logistic regression were incorporated into multivariate logistic regression. Statistical significance was defined as a 95% confidence interval and a P-value of less than .05.

RESULTS

The risk of CMetS increased twofold as age increased each year (P = .009), 1.2 times as the age at which cART began increased (P = .015), and 6 times with 1 or more co-morbidities (P = .028), according to the NCEP tool. Furthermore, significant NCEP-CMetS correlations were produced by a rise in diastolic blood pressure (P < .001) and cART duration (P = .006). Male gender was 99.9% less likely to be related to CMetS using the IDF tool, and the risk of CMetS increased fourfold with each unit increase in waist circumference (P < .001). Triglycerides and blood type "A" have been found to have substantial relationships with CMetS using both techniques.

CONCLUSION

According to the study, CMetS was found to be common in PLWHA. Age, time on cART, age when cART started, gender, co-morbidities, waist circumference, and diastolic blood pressure were all revealed to be significant predictors of CMetS. Triglycerides and blood type "A" were the only biomarkers found to be significant with CMetS using both the NCEP and IDF tools.

Cardiac Multimodality Imaging Assessment of Dystrophic Myocardial Calcification in a Human Immunodeficiency Virus-Infected Patient With Dilated Cardiomyopathy

Dystrophic myocardial calcification represents the sequelae of local tissue damage and cellular necrosis. We present the case of a 72-year-old man who presented with exertional chest pain. He had a medical history of human immunodeficiency virus (HIV) infection and chronic dilated cardiomyopathy with severe left ventricular (LV) systolic dysfunction and wall motion abnormalities at the inferior and lateral LV walls. A cardiac magnetic resonance (CMR) examination from 16 years ago showed a subendocardial late gadolinium enhancement (LGE) distribution consistent with prior myocardial infarction (MI). Recently, a pharmacological stress myocardial perfusion imaging by CMR had been positive for myocardial ischemia in the left descending coronary artery (LAD) territory. A cardiac CT angiography (CCTA) showed non-significant LAD obstruction <50% consistent with microvascular ischemia and the presence of dystrophic myocardial calcification as an unusual progression of a prior MI. Conservative approach and optimal medical therapy were employed in our patient, and there was no symptom progression during the two-month follow-up period.

Predictors of Current CD4+ T-Cell Count Among Women of Reproductive Age on Antiretroviral Therapy in Public Hospitals, Southwest Ethiopia

Background

HIV/AIDS is one of the major global public health problems. CD4 is a glycoprotein found on the surface of different immune cells. CD4 cell counts determine the need for screening and prophylactic interventions against common opportunistic infections in those with advanced HIV disease. Thus, this study aimed to assess the predictors of current CD4⁺ T-cell count among women of reproductive age on antiretroviral therapy in public hospitals, southwest Ethiopia.

Methods

A cross-sectional study was conducted from February to April 2018. A total of 422 participants in the three public hospitals were selected using a systematic random sampling method. Linear regression analyses were used to determine the important predictors of current CD4⁺ T-cell count at p-values of <0.05.

Results

A total of 422 women with a median age of 37.00 years participated in this study. More than one in ten (12.8%) respondents experienced immunological failure. An increased current CD4⁺ T-cell count was observed among patients with a tertiary level of education [β = 56.45, 95% CI (3.5, 109.4)], baseline WHO clinical stage II [β = 44.06, 95% CI (5.3, 82.9)], initial regimen of AZT+3TC+EFV [β = 167.23, 95% CI (100.4, 234.1)], with increased baseline CD4⁺ T-cell count [β = 0.35, 95% CI (0.2, 0.5)], and with increased time duration on ART [β = 14.36, 95% CI (6.304, 22.4)]. On the other hand, the current CD4⁺ T-cell count was lowered among patients with poor baseline adherence, opportunistic infection, and viral load of ≥1000 by 181.06 cells/mm³, 101.62 cells/mm³, and 137.53 cells/mm³ compared to good baseline adherence, no opportunistic infection and undetectable viral load, respectively.

Conclusion

The immunological failure was relatively low. Maintaining adherence, early identification and treatment of opportunistic infections, and minimizing viral load to undetectable levels may further decrease immunological failure.

Prevalence of cardiometabolic syndrome in HIV-infected persons: a systematic review

INTRODUCTION

HIV infected persons are twofold likely to experience a heart attack, stroke, and other forms of Cardiometabolic Syndrome (CMetS).

METHODS

Electronic searches of databases (MEDLINE and Google Scholar) were queried for articles written in English from 2000 to 2019.

RESULTS

In this review (16 publications), a total of 14,002 participants from 8 countries were included. Two continents contributed to 62.5% of the CMetS studies while 38.1% from Latin America and 24.4% from North America. The studies were conducted in 113 different centers, with an average study length of 2.8 years. The majority of the study designs were cross-sectional (62%) followed by a cohort study (25%) and clinical trials (12.5%). The mean age of the population enrolled was 41.9 years and 54.6% of the participants were males. The overall prevalence of CMetS using the National Cholesterol Education Adult Treatment Panel definition was 20.6%. Only 31.3% of the studies were reported using the International Diabetes Federation definition. Smoking and high blood pressure were reported as a risk factor in 62.5% of the studies, while diabetes (31.3%), family history of CMetS (25%), and cardiac vascular and cancer diseases were reported in 12.5% of the studies. The average duration of stay with HIV after confirmation was 5.23 + 1.4 (years + SD) and the median duration on HAART was 4.5 + 2.3 (years + SD).

CONCLUSIONS

CMetS was a common problem among HIV infected persons. Several RFs can contribute to the development of CMetS with smoking and hypertension highly interrelated.

PROSPERO-NUMBER

CRD42018107187.

Myocarditis and inflammatory cardiomyopathy: current evidence and future directions

Inflammatory cardiomyopathy, characterized by inflammatory cell infiltration into the myocardium and a high risk of deteriorating cardiac function, has a heterogeneous aetiology. Inflammatory cardiomyopathy is predominantly mediated by viral infection, but can also be induced by bacterial, protozoal or fungal infections as well as a wide variety of toxic substances and drugs and systemic immune-mediated diseases. Despite extensive research, inflammatory cardiomyopathy complicated by left ventricular dysfunction, heart failure or arrhythmia is associated with a poor prognosis. At present, the reason why some patients recover without residual myocardial injury whereas others develop dilated cardiomyopathy is unclear. The relative roles of the pathogen, host genomics and environmental factors in disease progression and healing are still under discussion, including which viruses are active inducers and which are only bystanders. As a consequence, treatment strategies are not well established. In this Review, we summarize and evaluate the available evidence on the pathogenesis, diagnosis and treatment of myocarditis and inflammatory cardiomyopathy, with a special focus on virus-induced and virus-associated myocarditis. Furthermore, we identify knowledge gaps, appraise the available experimental models and propose future directions for the field. The current knowledge and open questions regarding the cardiovascular effects associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are also discussed. This Review is the result of scientific cooperation of members of the Heart Failure Association of the ESC, the Heart Failure Society of America and the Japanese Heart Failure Society.

Receipt and predictors of smoking cessation pharmacotherapy among veterans with and without HIV

Smoking is highly prevalent among people living with HIV (PLWH) and increases cardiovascular risk. Pharmacotherapies such as nicotine replacement therapy (NRT), bupropion, and varenicline help to reduce smoking, though rates of receipt among PLWH compared with HIV-uninfected persons are unknown. Among 814 PLWH and 908 uninfected patients enrolled in the Veterans Aging Cohort Study (2012-2017) who reported current smoking, we used marginal multivariable log-linear regression models to estimate adjusted relative risks (ARR) of receiving pharmacotherapy by HIV status. We also assessed patient-level factors associated with pharmacotherapy receipt within each group. In multivariable analyses, receipt of NRT was less likely among PLWH relative to uninfected participants (ARR 0.77, 95% CI 0.67, 0.89). In both populations, documented mental health disorders and contemplation to quit were associated with greater likelihood of receiving pharmacotherapy. Further research is needed to explore potential treatment disparities.

Long-Term Impact of Calcium and Vitamin D Supplementation on Bone Density in HIV+ Patients with Documented Deficiencies

To assess the efficacy of long-term calcium and vitamin D treatment on bone mineral density (BMD) in HIV⁺ patients on combined antiretroviral therapy (cART). A retrospective, single-center cohort study. Between March 2010 and July 2012, 268 HIV⁺ patients were screened for vitamin D and calcium deficiency. Those with proven vitamin D or calcium deficiency received supplementation according to a predefined protocol, and were offered further evaluation of BMD by dual-energy X-ray absorptiometry (DEXA). Calcium and vitamin D status and BMD were assessed at baseline (T₀) and approximately one (T₁) and 4-6 years (T₂) later. Percentual change in BMD of the lumbar spine and hip was compared with reported rates of change in HIV⁺ patients on cART without standard calcium and vitamin D treatment. The prevalence of vitamin D deficiency and calcium deficiency was 46% and 43%, respectively. Thirteen percent of patients had secondary hyperparathyroidism at baseline. DEXA performed in patients with a deficiency revealed osteopenia in 40% and osteoporosis in 8% of patients. The expected long-term change in lumbar spine and hip BMDs at T₂ was -0.7%, -1.5%, and -1.5%, respectively. The measured changes were +2.3%, -0.6%, and -0.6%, respectively. The difference between measured and expected rate of change was significant for the lumbar spine (3.0%, p < .05), but not for the hip. Long-term vitamin D and calcium supplementation improves lumbar spine BMD of HIV⁺ patients with osteopenia or osteoporosis and with proven calcium and/or vitamin D deficiencies. Screening and treatment are recommended to become part of regular care.

Low nadir CD4+ T-cell counts predict gut dysbiosis in HIV-1 infection

Human immunodeficiency virus (HIV)-1 infection causes severe gut and systemic immune damage, but its effects on the gut microbiome remain unclear. Previous shotgun metagenomic studies in HIV-negative subjects linked low-microbial gene counts (LGC) to gut dysbiosis in diseases featuring intestinal inflammation. Using a similar approach in 156 subjects with different HIV-1 phenotypes, we found a strong, independent, dose-effect association between nadir CD4+ T-cell counts and LGC. As in other diseases involving intestinal inflammation, the gut microbiomes of subjects with LGC were enriched in gram-negative Bacteroides, acetogenic bacteria and Proteobacteria, which are able to metabolize reactive oxygen and nitrogen species; and were depleted in oxygen-sensitive methanogenic archaea and sulfate-reducing bacteria. Interestingly, subjects with LGC also showed increased butyrate levels in direct fecal measurements, consistent with enrichment in Roseburia intestinalis despite reductions in other butyrate producers. The microbiomes of subjects with LGC were also enriched in bacterial virulence factors, as well as in genes associated with beta-lactam, lincosamide, tetracycline, and macrolide resistance. Thus, low nadir CD4+ T-cell counts, rather than HIV-1 serostatus per se, predict the presence of gut dysbiosis in HIV-1 infected subjects. Such dysbiosis does not display obvious HIV-specific features; instead, it shares many similarities with other diseases featuring gut inflammation.

The palatine tonsil bacteriome, but not the mycobiome, is altered in HIV infection

Background

Microbial flora in several organs of HIV-infected individuals have been characterized; however, the palatine tonsil bacteriome and mycobiome and their relationship with each other remain unclear. Determining the palatine tonsil microbiome may provide a better understanding of the pathogenesis of oral and systemic complications in HIV-infected individuals. We conducted a cross-sectional study to characterize the palatine tonsil microbiome in HIV-infected individuals.

Results

Palatine tonsillar swabs were collected from 46 HIV-infected and 20 HIV-uninfected individuals. The bacteriome and mycobiome were analyzed by amplicon sequencing using Illumina MiSeq. The palatine tonsil bacteriome of the HIV-infected individuals differed from that of HIV-uninfected individuals in terms of the decreased relative abundances of the commensal genera Neisseria and Haemophilus. At the species level, the relative abundances and presence of Capnocytophaga ochracea, Neisseria cinerea, and Selenomonas noxia were higher in the HIV-infected group than those in the HIV-uninfected group. In contrast, fungal diversity and composition did not differ significantly between the two groups. Microbial intercorrelation analysis revealed that Candida and Neisseria were negatively correlated with each other in the HIV-infected group. HIV immune status did not influence the palatine tonsil microbiome in the HIV-infected individuals.

Conclusions

HIV-infected individuals exhibit dysbiotic changes in their palatine tonsil bacteriome, independent of immunological status.

Electronic supplementary material

The online version of this article (10.1186/s12866-018-1274-9) contains supplementary material, which is available to authorized users.

The HIV protease inhibitor, ritonavir, dysregulates human platelet function in vitro

There are 37 million people globally infected with the Human Immunodeficiency Virus (HIV). People living with HIV can achieve nearly normal lifespans due to the use of antiretroviral drugs (ARVs). However, people living with HIV experience chronic inflammation and increased risk for cardiovascular diseases (CVD) relative to uninfected people. While the cause for this risk is unclear, some ARVs have been associated with CVD, and it is speculated that some ARVs potentiate inflammation in infected individuals. Platelets are a critical link between inflammation and the development and progression of CVD, but the effects of ARVs on platelets are largely understudied. In this study, we examined the effects of ARVs on human platelet function in vitro. Our data show that the ARV ritonavir, a protease inhibitor, severely altered human platelet lipid mediator production (prostaglandin E2 and thromboxane) in both resting and activated platelets. Further characterization revealed that ritonavir altered measures of platelet hemostatic and thrombotic function that included significantly decreased platelet spreading, increased platelet aggregation, and trended toward increased clot strength. These data provide proof-of-principle that ARVs can directly dysregulate human platelets, possibly contributing to inflammation-related comorbidities. These data may provide mechanistic insight into the factors contributing to increased risk of CVD in people living with HIV, and may help guide future development of new HIV agents and ARV regimens that mitigate platelet dysregulation by ARVs.

Early Right Ventricular Dysfunction in Highly Selected (Totally Free from Cardiovascular Risk Factors and Other Comorbidities) Human Immunodeficiency Virus Patients: A Pilot Study with Advanced Echocardiography

Objective:

Human immunodeficiency virus (HIV) infection may also be associated with cardiac dysfunction, thus negatively affecting patients’ morbidity and mortality. This preliminary study aimed at evaluating whether bi-and three-dimensional (3D) strain echocardiographic facilities were able to identify alterations in the right ventricular (RV) function in highly selected – because free from cardiovascular risk factors and other comorbidities – HIV patients.

Materials and Methods:

Eight of these specific HIV patients (age: 32.0 ± 3.6 years; 7 months) treated with highly active antiretroviral therapy (HAART) were enrolled and compared with 8 sex-, age-, and cardiovascular risk profile-matched healthy individuals. All underwent clinical evaluation and transthoracic echocardiography coupled with tissue Doppler, two-dimensional (2D), and 3D speckle tracking imaging to examine their RV function.

Results:

All standard echocardiographic parameters resulted in the normal range, with no significant differences between HIV and controls. On the contrary, 2D longitudinal strain (16.1% ±1.6% vs. 17.8% ±0.9%, P = 0.02) and Global 3D strain (28.5% ±3.6% vs. 33.5% ±1.9%, P = 0.0002) were reduced in the HIV group. Moreover, Global 3D strain values showed a direct correlation with RV fractional area change values (r = 0.66, P = 0.005).

Conclusions:

2D longitudinal and 3D Global strain can identify an early asymptomatic RV impairment in HIV patients free from other risk factors and comorbidities. These findings seem to imply that also in treated with HAART and well-controlled HIV patients an early asymptomatic systolic RV dysfunction is present, as a distinctive and separated pathological entity compared with classic HIV-related pulmonary arterial hypertension and left ventricular dysfunction. In these patients, RV dysfunction is not revealed by standard echocardiography.

Cardiac complications in people living with human immunodeficiency virus/acquired immunodeficiency syndrome and their association with CD4+ T-cell count - A cross sectional study

Introduction:

Cardiac complications of HIV infection tend to occur late in the disease or are associated with related therapies and are therefore becoming more prevalent as therapy and longevity improve.

Materials and Methods:

The study was undertaken to study the common cardiovascular complications in Indian HIV patients and to their association with the CD4+ T-cell count.

Observations and Conclusion:

Prevalence of cardiac abnormality in our study was 24%. The abnormalities included LVDD (22%), pulmonary hypertension (12%), DCMP (12%), pericardial effusion (7%), left ventricular systolic dysfunction (5%), and right ventricular dysfunction (1%).

Modeling aging in HIV infection in nonhuman primates to address an emerging challenge of the post-ART era

The advent of antiretroviral therapy (ART) has dramatically improved both quality and length of life for subjects infected with human immunodeficiency virus (HIV), delaying or preventing progression to acquired immunodeficiency syndrome (AIDS). However, the virus induces aging-related changes to the immune system which confound treatment. Additionally, the normal physiologic events that occur during aging lead to deficiencies in immunity which not only exacerbate HIV pathogenesis but also trigger a variety of comorbidities. Here, the synergistic linkage between aging and HIV infection is examined in regard to the immunological and pathological mechanisms that drive both senescence and disease progression. The use of NHPs to investigate potential therapeutic strategies to control the deleterious consequences of aging with HIV infection is also reviewed.

HIV and coronary disease - When secondary prevention is insufficient

Highly active antiretroviral therapy (HAART) has created a new paradigm for human immunodeficiency virus (HIV)-infected patients, but their increased risk for coronary disease is well documented. We present the case of a 57-year-old man, co-infected with HIV-2 and hepatitis B virus, adequately controlled and with insulin-treated type 2 diabetes and dyslipidemia, who was admitted with non-ST elevation acute myocardial infarction. Coronary angiography performed on day four of hospital stay documented two-vessel disease (mid segment of the right coronary artery [RCA, 90% stenosis] and the first marginal). Two drug-eluting stents were successfully implanted. The patient was discharged under dual antiplatelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/day) and standard coronary artery disease medication. He was admitted to the emergency room four hours after discharge with chest pain radiating to the left arm and inferior ST-segment elevation myocardial infarction was diagnosed. Coronary angiography was performed within one hour and documented thrombosis of both stents. Optical coherence tomography revealed good apposition of the stent in the RCA, with intrastent thrombus. Angioplasty was performed, with a good outcome. The acute stent thrombosis might be explained by the thrombotic potential of HIV infection and diabetes. There are no specific guidelines regarding HAART in secondary prevention of acute coronary syndromes. A multidisciplinary approach is essential for optimal management of these patients.

Aggressive restenosis after percutaneous intervention in two coronary loci in a patient with human immunodeficiency virus infection

A 54-year-old black African woman, 22 years human immunodeficiency virus (HIV)-positive, presented with an acute coronary syndrome. She was taking two nucleoside reverse transcriptase inhibitors and two protease inhibitors. Viral load and CD4 count were stable. Angiography revealed a right coronary artery lesion, which was treated with everolimus eluting stent. She also underwent balloon angioplasty to the first diagonal. She re-presented on three different occasions and technically successful coronary intervention was performed. The patient has reported satisfactory compliance with dual anti platelet therapy throughout. She was successfully treated with surgical revascularisation. The patient did not experience any clinical recurrence on follow up. This case demonstrates exceptionally aggressive multifocal and recurrent instent restenosis in a patient treated for HIV infection, raising the possibility of an association with HIV infection or potentially components of retro viral therapy.

Oxidative Stress during HIV Infection: Mechanisms and Consequences

It is generally acknowledged that reactive oxygen species (ROS) play crucial roles in a variety of natural processes in cells. If increased to levels which cannot be neutralized by the defense mechanisms, they damage biological molecules, alter their functions, and also act as signaling molecules thus generating a spectrum of pathologies. In this review, we summarize current data on oxidative stress markers associated with human immunodeficiency virus type-1 (HIV-1) infection, analyze mechanisms by which this virus triggers massive ROS production, and describe the status of various defense mechanisms of the infected host cell. In addition, we have scrutinized scarce data on the effect of ROS on HIV-1 replication. Finally, we present current state of knowledge on the redox alterations as crucial factors of HIV-1 pathogenicity, such as neurotoxicity and dementia, exhaustion of CD4+/CD8+ T-cells, predisposition to lung infections, and certain side effects of the antiretroviral therapy, and compare them to the pathologies associated with the nitrosative stress.

Pericardial effusion with Mycobacterium avium complex in HIV-infected patients

Disseminated atypical Mycobacterium infection is a well-known opportunistic infection in HIV-infected patients with advanced immune deficiency before the introduction of combination antiretroviral therapy. Although the disseminated infection is now rare, few cases of localised infections are reported. A 38-year-old man was diagnosed with HIV infection during asymptomatic sexual health screening. Although he was asymptomatic on diagnosis, he had advanced immunodeficiency; therefore, combination antiretroviral therapy was started immediately. After 5 months of treatment, he developed pericardial effusion. Mycobacterium was detected from a culture of the pericardial fluid and Mycobacterium avium complex was identified using a gene probe test. He was treated with combination therapy for Mycobacterium infection and he fully recovered. Treatment continued for 4 years until he achieved adequate immune recovery.

Inflammatory Markers Associated With Subclinical Coronary Artery Disease: The Multicenter AIDS Cohort Study

Background

Despite evidence for higher risk of coronary artery disease among HIV+ individuals, the underlying mechanisms are not well understood. We investigated associations of inflammatory markers with subclinical coronary artery disease in 923 participants of the Multicenter AIDS Cohort Study (575 HIV+ and 348 HIV− men) who underwent noncontrast computed tomography scans for coronary artery calcification, the majority (n=692) also undergoing coronary computed tomography angiography.

Methods and Results

Outcomes included presence and extent of coronary artery calcification, plus computed tomography angiography analysis of presence, composition, and extent of coronary plaques and severity of coronary stenosis. HIV+ men had significantly higher levels of interleukin‐6 (IL‐6), intercellular adhesion molecule‐1, C‐reactive protein, and soluble‐tumor necrosis factor‐α receptor (sTNFαR) I and II (all P<0.01) and a higher prevalence of noncalcified plaque (63% versus 54%, P=0.02) on computed tomography angiography. Among HIV+ men, for every SD increase in log‐interleukin‐6 and log intercellular adhesion molecule‐1, there was a 30% and 60% increase, respectively, in the prevalence of coronary stenosis ≥50% (all P<0.05). Similarly, sTNFαR I and II in HIV+ participants were associated with an increase in prevalence of coronary stenosis ≥70% (P<0.05). Higher levels of interleukin‐6, sTNFαR I, and sTNFαR II were also associated with greater coronary artery calcification score in HIV+ men (P<0.01).

Conclusions

Higher inflammatory marker levels are associated with greater prevalence of coronary stenosis in HIV+ men. Our findings underscore the need for further study to elucidate the relationships of inflammatory pathways with coronary artery disease in HIV+ individuals.

Infectious and Non-infectious Etiologies of Cardiovascular Disease in Human Immunodeficiency Virus Infection

Background:

Increasing rates of HIV have been observed in women, African Americans, and Hispanics, particularly those residing in rural areas of the United States. Although cardiovascular (CV) complications in patients infected with human immunodeficiency virus (HIV) have significantly decreased following the introduction of antiretroviral therapy on a global scale, in many rural areas, residents face geographic, social, and cultural barriers that result in decreased access to care. Despite the advancements to combat the disease, many patients in these medically underserved areas are not linked to care, and fewer than half achieve viral suppression.

Methods:

Databases were systematically searched for peer-reviewed publications reporting infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients. Relevant articles cited in the retrieved publications were also reviewed for inclusion.

Results:

A variety of outcomes studies and literature reviews were included in the analysis. Relevant literature discussed the manifestations, diagnosis, treatment, and outcomes of infectious and non-infectious etiologies of cardiovascular disease in HIV-infected patients.

Conclusion:

In these medically underserved areas, it is vital that clinicians are knowledgeable in the manifestations, diagnosis, and treatment of CV complications in patients with untreated HIV. This review summarizes the epidemiology and causes of CV complications associated with untreated HIV and provide recommendations for management of these complications.

Correlates and Longitudinal Renal and Cardiovascular Implications of FGF23 Levels in HIV-Positive Individuals

Fibroblast growth factor23 (FGF23), an early marker of kidney dysfunction, is associated with cardiovascular death. Its role in HIV-positive individuals is unknown. We measured FGF23 in 100 HIV-negative and 191 HIV-positive nondiabetic adults with normal baseline estimated glomerular filtration rate (GFR). We measured GFR by iohexol annually, albumin-creatinine ratio (ACR) every 6 months, as well as pulse wave velocity, carotid plaque, and carotid intima media thickness (IMT) at baseline and 2 years. Progressive albuminuria was defined as follow-up ACR ≥2-fold than baseline and ≥30 mg/g. Regression models assessed associations of FGF23 with baseline factors and longitudinal changes in disease markers. FGF23 levels were similar in HIV serostatus. Among HIV-positive persons, factors independently associated with higher baseline FGF23 levels included female (adjusted ratio of geometric means [95% CI],1.46 [1.21,1.76]), serum phosphorus (1.20 [1.03,1.40]), HCV (1.31 [1.10,1.56]) and non-suppressed HIV RNA (1.27 [1.01,1.76]). At baseline, FGF23 was not associated with GFR, albuminuria, carotid plaque, or carotid IMT in cross-sectionally adjusted analysis of HIV-positive individuals. However, higher baseline FGF23 was associated with progressive albuminuria (odds ratio1.48 [95% CI]:1.05,2.08) and a more rapid increase in IMT (13 μm/year, 95% CI,3,24). These findings suggest a role for FGF23 in HIV-positive populations in identifying patients at greater risk for cardiovascular and kidney disease.

Influences of gender in metabolic syndrome and its components among people living with HIV virus using antiretroviral treatment in Hawassa, southern Ethiopia

Background

Data regarding the influences of gender in metabolic syndrome (MetS) among patients using antiretroviral treatment (ART) in Ethiopia is scarce. The aim of this study was to assess the influences of gender in MetS and its components among HIV-infected patients receiving ART.

Methods

A cross-sectional study was conducted between February 2012 and April 2013. Data on demographic, clinical and anthropometric characteristics were collected from 185 HIV patients using ART. Glucose and lipid profiles were measured from overnight fast blood. The International Diabetes Federation (IDF) and United States national cholesterol education program: adult treatment (US NCEP-ATP) panel III criteria were used to define MetS.

Result

A total number of 185 (36.8 % males and 63.2 % females) participants were recruited in this study. The overall prevalence of MetS was 24.3 and 17.8 %, diagnosed using IDF and NCEP-ATP criteria respectively. Using IDF criteria, MetS was significantly higher in females compared to males (33.3 vs. 8.8 %; p = <0.0001) respectively. Low HDL-c and central obesity were significantly higher MetS components in female compared to males (p = 0.003); and (p = <0.0001, using IDF and NCEP-ATP criteria) respectively. BMI >25 kg/m² was significantly associated with MetS in both IDF and NCEP-ATP criteria: unadjusted (UOR) and adjusted odds ratio (AOR) with 95 % CI were 3.0 (1.3–6.5) and 3.8 (1.5–9.8); as well as 3.2 (1.4–7.4) and 3.4 (1.4–7.4) respectively. Furthermore age >40 years was significantly associated with MetS using NCEP-ATP: UOR and AOR (95 % CI) were 3.1 (1.2–8.3), and 3.8 (1–13.70) respectively.

Conclusion

Comprehensive medical care approach including with MetS components are a crucial instruments in order to minimize the risk of developing cardiovascular diseases in HIV-infected patients using ART.

HIV, highly active antiretroviral therapy and the heart: a cellular to epidemiological review

The advent of potent highly active antiretroviral therapy (HAART) for persons infected with HIV-1 has led to a "new" chronic disease with complications including cardiovascular disease (CVD). CVD is a significant cause of morbidity and mortality in persons with HIV infection. In addition to traditional risk factors such as smoking, hypertension, insulin resistance and dyslipidaemia, infection with HIV is an independent risk factor for CVD. This review summarizes: (1) the vascular and nonvascular cardiac manifestations of HIV infection; (2) cardiometabolic effects of HAART; (3) atherosclerotic cardiovascular disease (ASCVD) risk assessment, prevention and treatment in persons with HIV-1 infection.

Lipid metabolism in patients infected with Nef-deficient HIV-1 strain

BACKGROUND

HIV protein Nef plays a key role in impairing cholesterol metabolism in both HIV infected and bystander cells. The existence of a small cohort of patients infected with Nef-deficient strain of HIV presented a unique opportunity to test the effect of Nef on lipid metabolism in a clinical setting.

METHODS

Here we report the results of a study comparing six patients infected with Nef-deficient strain of HIV (ΔNefHIV) with six treatment-naïve patients infected with wild-type HIV (WT HIV). Lipoprotein profile, size and functionality of high density lipoprotein (HDL) particles as well as lipidomic and microRNA profiles of patient plasma were analyzed.

RESULTS

We found that patients infected with ΔNefHIV had lower proportion of subjects with plasma HDL-C levels <1 mmol/l compared to patients infected with WT HIV. Furthermore, compared to a reference group of HIV-negative subjects, there was higher abundance of smaller under-lipidated HDL particles in plasma of patients infected with WT HIV, but not in those infected with ΔNefHIV. Lipidomic analysis of plasma revealed differences in abundance of phosphatidylserine and sphingolipids between patients infected with ΔNefHIV and WT HIV. MicroRNA profiling revealed that plasma abundance of 24 miRNAs, many of those involved in regulation of lipid metabolism, was differentially regulated by WT HIV and ΔNefHIV.

CONCLUSION

Our findings are consistent with HIV protein Nef playing a significant role in pathogenesis of lipid-related metabolic complications of HIV disease.

Highly active antiretroviral therapy and dyslipidemia in people living with HIV/AIDS in Fako Division, South West Region of Cameroon

Background

The advent of HAART has been associated with a profound reduction in morbidity and mortality from HIV/AIDS. However, side effects and toxicities associated with HAART may lead to an increased risk for cardiovascular diseases. The aim of this study was to determine the prevalence of dyslipidemia and determining factors of derangements in lipid profile associated with the use of HAART regimens in people living with HIV/AIDS in Fako Division of the South West Region of Cameroon.

Methods

This cross-sectional study was conducted between March and August 2014. Lipid profile was determined after overnight fast and dyslipidemia diagnosed according to the US National Cholesterol Education Program III criteria. Socio-demographic characteristics were also collected using a questionnaire. Data was analyzed using STATA; chi-square test, student’s t-test, ANOVA and logistic regressions were computed.

Results

Two hundred and nine participants were recruited including 157 (75.1 %) on HAART and 52 (24.9 %) HAART-naïve. Antiretrovirals were drugs containing two nucleoside backbones (zidovudine/ /lamivudine/tenofovir) with either a non-nucleoside (nevirapine/efavirenz) or a protease inhibitor (lopinavir). No patient was treated with statins. Their mean age was 43.4 (±11.0) years. The mean CD4⁺ T cell count was 425 (±281) cells/μl after mean duration of HIV infection of 54.8 (±43.9) months and mean duration on ART of 63.7 (±41.4) months. The prevalence of total cholesterol (≥ 200 mg/dL) was 51.0 % in patients on HAART and 9.6 % pre-HAART patients (p < 0.0001), whereas LDL-cholesterol ≥ 130 mg/dL occurred in 36.9 % and in 7.7 % respectively, (p = 0.0001). Receiving HAART (adjusted odds ratio =6.24, 95 % CI: 2.33–17.45, p < 0.0001) and HIV duration of 42 months and more (aOR = 2.26, 95 % CI: 1.16–4.42, p = 0.017) were independently associated with total cholesterol ≥ 200 mg/dL. Receiving HAART (aOR = 5.28, 95 % CI: 1.17–16.32, p = 0.004) was independently associated with raised LDL-cholesterol values. The adjusted odds ratio (95 % CI) of BMI ≥ 25.0 kg/m² versus BMI < 25.0 kg/m² was 3.25 (1.44–7.34) for triglycerides ≥ 150 mg/dL.

Conclusion

HAART regimens were significantly associated with atherogenic lipid profile. Lipid profile should be monitored in HIV/AIDS patients on therapy so that any negative effects of HAART are optimally managed.

Contemplation of smoking cessation and quit attempts in human immunodeficiency virus-infected and uninfected veterans

BACKGROUND

As antiretroviral treatments prolong life in human immunodeficiency virus (HIV)-infected patients, smoking cessation is now a top priority. However, studies of HIV-infected smokers have not been conducted with uninfected controls. In this study, researchers determined factors associated with contemplating smoking cessation and making a prior quit attempt among HIV-infected and uninfected smoking veterans.

METHODS

Between 2005 and 2007, 1,027 HIV-infected and 794 uninfected smokers were identified as part of the Veterans Aging Cohort Study (VACS). Stratifying by HIV status, adjusted odds ratios (AORs) were calculated using logistic regression to identify factors associated with contemplating smoking cessation and making a prior quit attempt.

RESULTS

Most participants (66 % of HIV-infected vs. 68 % of uninfected; P = .46) were contemplating cessation, and 56 % of both groups (P = .99) had attempted to quit in the last year. In stratified multivariable analyses, HIV-infected smokers with recent pulmonary disease diagnoses were more likely to have made a quit attempt (AOR = 4.93, 95 % confidence interval [CI] = 1.41-17.17). Both HIV-infected and uninfected patients with unhealthy alcohol use were less likely to be contemplating cessation (AOR = 0.66, 95 % CI = 0.49-0.90 and 0.71, 95 % CI = 0.50-1.00). HIV-infected smokers who reported unhealthy alcohol use were also less likely to have made a quit attempt in the last year (AOR = 0.68, 95 % CI = 0.51-0.91).

CONCLUSIONS

Patient-level interest and motivation are not major barriers to smoking cessation among HIV-infected veterans. Targeting HIV-infected smokers with a recent pulmonary disease diagnosis may improve sustained smoking cessation. Unhealthy alcohol use appears to be a key modifiable risk factor. Smoking cessation rates may be improved by combining interventions for smoking and alcohol use for HIV-infected patients.

Effects of pravastatin, phytosterols, and combination therapy on lipid profile in HIV-infected patients: an open-labelled, randomized cross-over study

BACKGROUND

To determine the effects of 40 mg of pravastatin, 2 g of phytosterols, and combination therapy on lipid profiles and to compare the reduction of LDL cholesterol between combination therapy and monotherapy.

METHODS

Thirty-six HIV-infected patients treated with ARVs who had high LDL cholesterol levels but no current usage of any lipid-lowering agents were enrolled into the open-labelled, randomized, cross-over study. All patients were assigned randomly into one of four intervention groups: (1) pravastatin 40 mg cross-over to the combination of pravastatin 40 mg and phytosterols 2 g (combination group), (2) the combination group cross-over to pravastatin 40 mg, (3) phytosterols 2 g cross-over to the combination group, and (4) the combination group cross-over to phytosterols 2 g. Each active treatment lasted 4 weeks with a wash-out period of 4 weeks.

RESULTS

The baseline mean TC, TG, HDL-c, and LDL-c levels in 36 HIV patients were 248.09 ± 34.73, 172.36 ± 125.44, 54.92 ± 16.67, and 175.13 ± 29.00 mg/dl, respectively. Pravastatin, phytosterols, and combination therapy reduced TC and LDL-c but TG and HDL-c were not significantly different from the baselines. The mean LDL-c reductions in the pravastatin, phytosterols, and the combination groups were 28.76 ± 9.32, 9.12 ± 7.84, and 27.08 ± 15.58%, respectively. The LDL-c levels in the pravastatin and combination groups were reduced more than in the phytosterols group (p < 0.01). There was no difference in the LDL-c reduction between the combination and pravastatin monotherapy groups (-25.61 ± 10.43 vs. -28.12 ± 14.07%, p = 0.555).

CONCLUSION

Pravastatin had moderate potency on LDL-c lowering in HIV patients but could not bring LDL-c to goal. Adding phytosterols to pravastatin for a 4-week duration could not demonstrate any additional lipid-lowering effect

TRIAL REGISTRATION

Thai Clinical Trial Registry: TCTR20150126002 date: January 23, 2015.

The prevalence of comorbidities among people living with HIV in Brent: a diverse London Borough

Background HIV has changed from a rapidly deteriorating illness to a complex chronic disease, with increasing incidences of comorbidity, including cancer, and liver, lung and cardiovascular diseases. North West London has 6719 individuals living with the human immunodeficiency virus (HIV), 873 of whom reside in the London Borough of Brent. Traditionally, commissioning services have focused on HIV therapy alone without considering how comorbidity affects treatment outcome and total service costs. Setting The setting for the study was NHS Brent Primary Care Trust, London UK. Question What associated comorbidities are present in people in Brent (London, UK) living with HIV, and how common are they? Methods A point-prevalence audit of retrospective data was conducted on all HIV-positive patients in Brent (financial year 2011/12). Data were collected from genito-urinary medicine (GUM) services, community services and general practitioners (GPs) on HIV diagnosis, patient demographics and past/current comorbidities: hepatitis B and C, cardiovascular disease, diabetes and mental health disorders. Results This study identified that 29% of people living with HIV/AIDS (PLWHA) in Brent have at least one comorbidity. The most common was hepatitis, followed by mental health disorders and cardiovascular disease (CVD). Comorbidity was more likely in older male patients (in particular CVD and diabetes) and White patients (except for diabetes which was more common in Asian groups). Discussion/Conclusion Many PLWHA in Brent suffer from a number of other conditions, which appear largely independent of HIV. Findings confirm the need to treat HIV as a long-term condition, including patient education, empowerment and encouraging self-management. The multi-morbidity of many PLWHA suggests a role for both primary care and collaborative, holistic, patient-centred and individualised healthcare. Service providers and commissioners need to consider comorbidities in their treatment of and provision of services for PLWHA. This study also highlighted the need for services to address limitations of their data collection systems.

Endothelial activation and cardiometabolic profiles of treated and never-treated HIV infected Africans

OBJECTIVE

The role the human immunodeficiency virus (HIV) and antiretroviral treatment on endothelial activation, and the subsequent relationship with cardiovascular disease, is not well understood. We investigated endothelial activation, inflammatory and cardiometabolic profiles, and measures of vascular structure and function of 66 antiretroviral treated (ART), 78 never-treated (no-ART) HIV infected and 165 HIV free Africans.

METHODS

Blood samples were obtained for biochemical analysis and blood pressure, pulse wave velocity (PWV) and carotid intima-media thickness (IMT) measurements were performed.

RESULTS

The HIV infection duration was at least five years and the treatment 2.86±0.13 years. The intracellular adhesion molecule (ICAM) and vascular cell adhesion molecule (VCAM) levels were elevated in the HIV infected groups compared to the controls. The odds of higher adhesion molecule levels were increased when HIV infected (especially in the no-ART group); OR no-ART vs. no-HIV: ICAM 3.92 (2.2-7.0); VCAM 16.2 (7.5-35). ICAM and VCAM associated with HIV status and interleukin-6 (IL-6) in the total group (all p<0.01). In both HIV infected groups VCAM associated inversely with CD4 counts (no-ART: β=-0.28, p=0.01; ART: β=-0.22, p=0.07) and TC (no-ART: β=-0.36, p<0.01; ART: β=-0.27, p=0.03). The ART group had an unfavourable lipid profile compared to the no-ART group. The inflammatory markers (C-reactive protein (CRP) and IL-6), PWV and IMT did not differ between the three groups.

CONCLUSION

HIV infected Africans showed endothelial activation when compared to HIV free controls. The endothelial activation was not accompanied by increased inflammation (as measured with CRP and IL-6), arterial stiffness or sub-clinical atherosclerosis.

Unusual Response of Subclavian In-Stent Restenosis to Balloon Angioplasty in a Patient with HIV

Human Immunodeficiency Virus (HIV) infection and use of protease inhibitors have been associated with accelerated atherosclerosis. Increased rates of coronary in-stent restenosis are reported in these patients. There is limited data available on peripheral vascular disease interventions on these patients. Herein we report an aggressive subclavian in-stent restenosis with an unexpected response to balloon angioplasty treatment with a large, mobile tissue flap formation and its treatment with another stent.

Impact of HIV infection on cardiac deformation

AIM

The aim of this study was to detect abnormalities in left ventricular myocardial function due to HIV (human immunodeficiency virus) infection without established cardiovascular disease.

METHODS

An echocardiogram was performed in 50 asymptomatic HIV-infected patients (age 41 ± 6 years, 64% male) and in 20 healthy individuals. Conventional echocardiography and pulsed tissue Doppler imaging (TDI) were performed according to the guidelines. The strain rate of the basal segments was obtained with color tissue Doppler and used to evaluate systolic strain rate (SRS), early diastolic strain rate (SRE) and late diastolic strain rate (SRA). Longitudinal, radial and circumferential strain were assessed by 2D speckle tracking.

RESULTS

The mean duration of HIV infection was 10 ± 5 years, CD4 count was 579 ± 286 cells/mm³, 32% had detectable viral load, and 86% were under treatment. Of the HIV-infected patients, one had grade 1 diastolic dysfunction. The groups were not different except for E wave (HIV 0.72 ± 0.17 m/s vs. control 0.84 ± 0.16 m/s, p=0.01), longitudinal strain (-19.5 ± 1.9% vs. -21 ± 2%, p=0.005), SRS (-1.1 ± 0.28 s⁻¹ vs. -1.3 ± 0.28 s⁻¹, p=0.02) and SRE (1.8 ± 0.4 s⁻¹ vs. 2.2 ± 0.4 s⁻¹, p<0.001), but only SRS (p=0.03, 95% CI 0.036; 0.67) and SRE (p=0.001, 95% CI -0.599; -0.168) had independent value.

CONCLUSION

In an HIV-infected population without established cardiovascular disease, myocardial deformation abnormalities can be detected with strain and strain rate, revealing markers of myocardial injury.

Long-term use of first-line highly active antiretroviral therapy is not associated with carotid artery stiffness in human immunodeficiency virus-positive patients

Objective

To evaluate whether or not highly active antiretroviral therapy is associated with carotid artery stiffness in human immunodeficiency virus-positive patients in Henan Province, China.

Method

Fifty human immunodeficiency virus-positive patients with at least a 5-year history of highly active antiretroviral therapy use and 50 human immunodeficiency virus-positive patients without a history of highly active antiretroviral therapy use were enrolled in this study. Carotid artery intima-media thickness and stiffness were determined by quantitative inter-media thickness and quantitative artery stiffness, respectively.

Results

No statistically significant difference in carotid artery intima-media thickness and stiffness was observed between groups. A significant association between human immunodeficiency virus infection time and carotid artery stiffness was observed, but no significant association between human immunodeficiency virus infection time and intima-media thickness was found. No significant association between intima-media thickness, stiffness, and CD4⁺ and CD8⁺ T-cell counts were observed.

Conclusion

The first-line highly active antiretroviral therapy currently used in China is not associated with carotid artery stiffness in human immunodeficiency virus-positive patients with good highly active antiretroviral therapy compliance. Human immunodeficiency virus may play a role in the development of atherosclerosis.

Pattern of congestive heart failure in a Kenyan paediatric population

Background

Heart failure in children is a common cause of morbidity and mortality, with high socio-economic burden. Its pattern varies between countries but reports from Africa are few. The data are important to inform management and prevention strategies.

Objective

To describe the pattern of congestive heart failure in a Kenyan paediatric population.

Methods

This was a retrospective study done at Kenyatta National Hospital, Nairobi Kenya. Records of patients aged 12 years and younger admitted with a diagnosis of heart failure between January 2006 and December 2010 were examined for mode of diagnosis, age, gender, cause, treatment and outcome. Data were analysed using the Statistical Programme for Social Scientists version 16.0 for windows, and presented in tables, bar and pie charts.

Results

One hundred and fifty-eight cases (91 male, 67 female) patients’ records were analysed. The mean age was 4.7 years, with a peak at 1–3 years. The male:female ratio was 1.4:1. All the cases were in New York Heart Association (NYHA) class II–IV. Evaluation of infants was based on the classification proposed by Ross et al. (1992). Diagnosis was made based on symptoms and signs combined with echocardiography (echo) and electrocardiography (ECG) (38%); echo alone (12.7%); ECG, echo and chest X-ray (CXR) (11.4%); and ECG alone (10.8%). The underlying cause was established on the basis of symptoms, signs, blood tests, CXR, echo and ECG results. Common causes were infection (22.8%), anaemia (17.1%), rheumatic heart disease (14.6%), congenital heart disease (13.3%), cardiomyopathy (7.6%), tuberculosis and human immunodeficiency virus (6.9% each); 77.9% of patients recovered, 13.9% after successful surgery, and 7.6% died.

Conclusion

Congestive heart failure is not uncommon in the Kenyan paediatric population. It occurs mainly before five years of age, and affects boys more than girls. The majority are due to infection, anaemia, and rheumatic and congenital heart diseases. This differs from those in developed countries, where congenital heart disease and cardiomyopathy predominate. The majority of children usually recover. Prudent control of infection and correction of anaemia are recommended.

Nonadministration of thromboprophylaxis in hospitalized patients with HIV: a missed opportunity for prevention?

BACKGROUND

Hospitalized patients with human immunodeficiency virus (HIV) appear to be at increased risk of venous thromboembolism. Previous work at our institution has demonstrated that the proportion of doses administered varies between patients and locations.

OBJECTIVE

To compare the proportion of doses of thromboprophylaxis not administered between patients with and without HIV.

DESIGN

Using retrospective data, the proportion of nonadministered doses was determined in all hospitalized adults and stratified by HIV status.

SETTING

Large, urban, academic medical center in Baltimore, Maryland.

PATIENTS

Data were available for 4947 patient visits, 583 of which were by patients with HIV. Most visits by patients with HIV were to a designated HIV care unit.

MEASUREMENTS

Proportion of doses of thromboprophylaxis not administered, and documented reasons for dose nonadministration.

RESULTS

A total of 42,870 doses were prescribed. The proportion of doses not administered was greater for patients with HIV (23.5%) compared with patients without HIV (16.1%, odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.49-1.70, P < 0.001). Documented dose refusal accounted for a greater proportion of nonadministered doses in patients with HIV (15.9% vs 10.8%, OR: 1.56, 95% CI: 1.43-1.70, P < 0.0001). On the HIV care unit, the proportion of doses not administered was greater for patients with HIV (26.4% vs 13.1%, OR: 2.39, 95% CI: 1.93-2.96, P < 0.001). Within this unit, documented dose refusal was greater for patients with HIV (13.7% vs 10.7%, OR: 1.32, 95% CI: 1.16-1.51, P < 0.0001).

CONCLUSIONS

Nonadministration and documented refusal of thromboprophylaxis appear to be more common in patients with HIV at our institution.

Acute coronary thrombosis and multiple coronary aneurysms in a 22-year-old man with the human immunodeficiency virus

The human immunodeficiency virus (HIV) can cause diverse cardiovascular complications. In HIV patients on antiretroviral therapy, the prevalence of myocardial infarction has steadily increased over the years. Young patients who are naïve to antiretroviral therapy and who experience coronary events are not well represented in the medical literature. We describe the case of a 22-year-old man, infected with HIV for 4 years and never treated with antiretroviral therapy, who emergently presented with a non-ST-segment-elevation myocardial infarction. Coronary angiograms revealed thrombosis and multiple coronary artery aneurysms; however, no areas of atherosclerotic stenosis were apparent. He was successfully treated with coronary stenting, antiplatelet therapy, and anticoagulation. Nine months after the initial presentation, he exhibited excellent exercise capacity, and no ischemia was evident. We discuss the various therapeutic approaches in this case.

HIV protein Nef causes dyslipidemia and formation of foam cells in mouse models of atherosclerosis

Patients with HIV are at an increased risk of cardiovascular disease. In this study we investigated the effect of Nef, a secreted HIV protein responsible for the impairment of cholesterol efflux, on the development of atherosclerosis in two animal models. ApoE(-/-) mice fed a high-fat diet and C57BL/6 mice fed a high-fat, high-cholesterol diet were injected with recombinant Nef (40 ng/injection) or vehicle, and the effects of Nef on development of atherosclerosis, inflammation, and dyslipidemia were assessed. In apoE(-/-) mice, Nef significantly increased the size of atherosclerotic lesions and caused vessel remodeling. Nef caused elevation of total cholesterol and triglyceride levels in the plasma while reducing high-density lipoprotein cholesterol levels. These changes were accompanied by a reduction of ABCA1 abundance in the liver, but not in the vessels. In C57BL/6 mice, Nef caused a significant number of lipid-laden macrophages presented in adventitia of the vessels; these cells were absent from the vessels of control mice. Nef caused sharp elevations of plasma triglyceride levels and body weight. Taken together, our findings suggest that Nef causes dyslipidemia and accumulation of cholesterol in macrophages within the vessel wall, supporting the role of Nef in pathogenesis of atherosclerosis in HIV-infected patients.-Cui, H. L., Ditiatkovski, M., Kesani, R., Bobryshev, Y. V., Liu, Y., Geyer, M., Mukhamedova, N., Bukrinsky, M., Sviridov, D. HIV protein Nef causes dyslipidemia and formation of foam cells in mouse models of atherosclerosis.

Drug Interactions Between Antiplatelet or Novel Oral Anticoagulant Medications and Antiretroviral Medications

Objective: To review potential drug interactions between antiretroviral (ARV) medications and antiplatelets or novel oral anticoagulants (NOACs). Data Sources: A literature search of MEDLINE, PubMed, EMBASE, International Pharmaceutical Abstracts, and Google Scholar was performed using the search terms (1) clopidogrel or ticagrelor or prasugrel, (2) dabigatran or rivaroxaban or apixaban, and (3) antiretrovirals. Study Selection and Data Extraction: Any English language study or case report describing a drug interaction between an ARV and an antiplatelet or NOAC was included. Additional information was taken from pharmacokinetic studies of individual agents alone or information from similar drug interactions. Results: Two studies were identified through the literature search: one reporting an in vivo interaction between ritonavir and prasugrel and the other an in vitro interaction between efavirenz and clopidogrel. A case report describing a drug interaction between nevirapine and rivaroxaban was also located. Information from pharmacokinetic studies and from similar drug interactions allowed for a comprehensive review of potential drug interactions. Conclusions: There are potential drug interactions between ARVs, antiplatelet agents or NOACs. Management of these interactions may include selecting ARVs with a lower potential for drug interactions or choosing antiplatelet agents or NOACs least likely to interact with ARVs. With protease inhibitors or cobicistat, clopidogrel and dabigatran do not appear to have clinically significant interactions. Nonnucleoside reverse transcriptase inhibitors have a low potential for interactions with prasugrel and dabigatran. Clinically significant drug interactions are unlikely to occur between antiplatelet agents or NOACs and nucleoside reverse transcriptase inhibitors raltegravir, dolutegravir, or maraviroc.