Cardiovascular disease in adult and pediatric HIV/AIDS

Relationship of sleep disorders with long-term complications and health-related quality of life in people with well-controlled human immunodeficiency virus

ABSTRACT

Although sleep disorders are common in patients with human immunodeficiency virus (HIV) infection, they have not been adequately evaluated under currently advanced treatments, mainly with integrase strand transfer inhibitors. However, the relationship of sleep disorders with long-term complications and quality of life (QOL) status in patients infected with HIV is still poorly understood. Such associations are important in the management of outpatients with HIV. Hence, this study aimed to evaluate these associations.This cross-sectional observational study assessed the QOL changes of patients with HIV before and after the treatment regimen change. Male patients with well-controlled HIV who attended our hospital and changed HIV medications for reasons other than treatment failure between October 2019 and September 2021 were included. At the time of regimen change, sleep disorder status was assessed according to the Pittsburgh sleep quality index (PSQI), and health-related QOL (HRQOL) was assessed using the medical outcomes study 8-item short form health survey. In addition, we collected information on age, blood tests, and long-term comorbid conditions present during the evaluation. The HIV treatment regimen was also reviewed.Out of 45 male Japanese patients with HIV that were included in this study, 24 (53.3%) and 21 (46.7%) were classified into the sleep disorder group and nonsleep disorder group, respectively, according to their PSQI scores. The sleep disorder group had a significantly lower HRQOL mental component summary (P = .0222) than the nonsleep disorder group. The prevalence rates of hypertension, dyslipidemia, and diabetes mellitus were not significantly different between the 2 groups. In addition, a significant correlation was observed between PSQI scores and the HRQOL status (mental component summary, P = .0450; physical component summary, P = .0350).Sleep disorders remain common in patients with well-controlled HIV infection receiving current treatment. Sleep disorder is significantly associated with a low HRQOL in these patients. Hence, sleep status evaluation is necessary to improve HIV management.

Altered Lipid Profiles and Vaccine Induced-Humoral Responses in Children Living With HIV on Antiretroviral Therapy in Tanzania

People living with HIV, even under therapy, have a high burden of age-related co-morbidities including an increased risk of dyslipidemia (which often predisposes to cardiovascular diseases) and immune-aging. In this study, lipid profiles and antibody responses to measles and pertussis toxin vaccines were compared between ART experienced HIV+ children (n=64) aged 5-10 years, and their age- and sex-matched HIV- controls (n=47). Prevalence of high-density lipoprotein cholesterol (HDL-c) and triglyceride-driven dyslipidemia was higher among treated HIV+ children than in controls (51.6% vs 27.7% respectively, p < 0.019). In a multivariate Poisson regression model adjusted for age, sex and BMI, the association between low HDL-c, hypertriglyceridemia and HIV remained significantly high (for HDL-c: ARR: 0.89, 95% CI: 0.82 - 0.96, p = 0.003; for triglycerides: ARR: 1.54, 95% CI: 1.31 - 1.81, p < 0.001). Among HIV+ children, the use of lopinavir/ritonavir, a protease-based antiretroviral therapy was also associated elevation of triglyceride levels (p = 0.032). Also, HIV+ children had a 2.8-fold reduction of anti-measles IgG titers and 17.1-fold reduction of anti-pertussis toxin IgG levels when compared to HIV- children. Our findings suggest that dyslipidemia and inadequate vaccine-induced antibody responses observed in this population of young African HIV+ children might increase their risk for premature onset of cardiovascular illnesses and acquisition of preventable diseases.

Incidence and Predictors of Hypertension Among HIV Patients Receiving ART at Public Health Facilities, Northwest Ethiopia: A One-Year Multicenter Prospective Follow-Up Study

Background

The introduction of highly active retroviral therapy has dramatically reduced mortality and improved survival among HIV patients. However, there is a possible risk of comorbid complications such as hypertension. Little evidence is available regarding the incidence of hypertension among HIV patients receiving anti-retroviral therapy in Ethiopia.

Purpose

To assess the incidence and predictors of hypertension among HIV positive patients receiving ART at Public Health Facilities, Northwest Ethiopia.

Patients and Methods

A one-year prospective follow-up study was conducted among a cohort of 302 new adult individuals initiating on a standard anti-retroviral therapy regimen with a median (IQR) age of 35 years (IQR=30-41). A pretested data extraction checklist was used to extract baseline patient records. The collected data were entered into Epi-Data version 3.1 and exported to STATA version 14 for analysis. The incidence rate was calculated, and a Kaplan-Meier survival curve was used to estimate the survival probabilities of developing hypertension. Cox proportional hazards model was fitted to identify the predictors of hypertension.

Results

About 40 (13.25) new hypertensive cases were observed during the follow-up period, and the remaining 262 (86.75%) were censored. The overall incidence rate of hypertension was 16.35 per 1000 person-month with 2447 patient-month observations. Male sex (AHR = 2.45, 95% CI: 1.02, 6.14), old age (AHR = 2.83, 95% CI: 1.08, 7.45), high BMI (AHR = 6.54, 95% CI: 2.03, 21.13), diabetic comorbidity (AHR = 2.36, 95% CI: 1.07, 5.22), and patients who were on Zidovudine (AZT)-based ART regimen (AHR =3.47, 95% CI: 1.10, 10.94) were significant predictors for the development of hypertension.

Conclusion

The findings of this study revealed that incident hypertension is a common problem among HIV patients receiving ART. Routine monitoring of blood pressure and screening and treating high blood pressure should be an integral part of follow-up for HIV patients in ART clinics.

The coArtHA trial-identifying the most effective treatment strategies to control arterial hypertension in sub-Saharan Africa: study protocol for a randomized controlled trial

BACKGROUND

Arterial hypertension is the most prevalent risk factor for cardiovascular disease in sub-Saharan Africa. Only a few and mostly small randomized trials have studied antihypertensive treatments in people of African descent living in sub-Saharan Africa.

METHODS

In this open-label, three-arm, parallel randomized controlled trial conducted at two rural hospitals in Lesotho and Tanzania, we compare the efficacy and cost-effectiveness of three antihypertensive treatment strategies among participants aged ≥ 18 years. The study includes patients with untreated uncomplicated arterial hypertension diagnosed by a standardized office blood pressure ≥ 140/90 mmHg. The trial encompasses a superiority comparison between a triple low-dose antihypertensive drug combination versus the current standard of care (monotherapy followed by dual treatment), as well as a non-inferiority comparison for a dual drug combination versus standard of care with optional dose titration after 4 and 8 weeks for participants not reaching the target blood pressure. The sample size is 1268 participants with parallel allocation and a randomization ratio of 2:1:2 for the dual, triple and control arms, respectively. The primary endpoint is the proportion of participants reaching a target blood pressure at 12 weeks of ≤ 130/80 mmHg and ≤ 140/90 mmHg among those aged < 65 years and ≥ 65 years, respectively. Clinical manifestations of end-organ damage and cost-effectiveness at 6 months are secondary endpoints.

DISCUSSION

This trial will help to identify the most effective and cost-effective treatment strategies for uncomplicated arterial hypertension among people of African descent living in rural sub-Saharan Africa and inform future clinical guidelines on antihypertensive management in the region.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04129840 . Registered on 17 October 2019 ( https://www.clinicaltrials.gov/ ).

Prevalence and incidence of pre-diabetes and diabetes mellitus among people living with HIV in Ghana: Evidence from the EVERLAST Study

BACKGROUND

Available data from high-income countries suggest that people living with HIV (PLWH) have a four-fold higher risk of diabetes compared with HIV-negative people. In sub-Saharan Africa, with 80% of the global burden of HIV, there is a relative paucity of data on the burden and determinants of prevalent and incident dysglycaemia.

OBJECTIVES

To assess the prevalence and incidence of pre-diabetes (pre-DM) and overt diabetes mellitus (DM) among PLWH in a Ghanaian tertiary medical centre.

METHODS

We first performed a cross-sectional comparative analytical study involving PLWH on combination antiretroviral therapy (cART) (n = 258), PLWH not on cART (n = 244) and HIV-negative individuals (n = 242). Diabetes, pre-DM and normoglycaemia were defined as haemoglobin A1C (HBA1c) > 6.5%, in the range 5.7-6.4% and < 5.7% respectively. We then prospectively followed up the PLWH for 12 months to assess rates of new-onset DM, and composite of new-onset DM and pre-DM. Multivariate logistic regression models were fitted to identify factors associated with dysglycaemia among PLWH.

RESULTS

The frequencies of DM among PLWH on cART, PLWH not on cART and HIV-negative individuals were 7.4%, 6.6% and 7.4% (P = 0.91), respectively, while pre-DM prevalence rates were 13.2%, 27.9% and 27.3%, respectively (P < 0.0001). Prevalent DM was independently associated with increasing age [adjusted odds ratio (95% confidence interval) (aOR, 95% CI) = 1.82 (1.20-2.77) for each 10-year rise], male sex [aOR = 2.64 (1.20-5.80)] and log(triglyceride/HDL cholesterol) [aOR = 8.54 (2.53-28.83)]. Prevalent pre-DM was independently associated with being on cART [aOR (95% CI) = 0.35 (0.18-0.69)]. There were a total of 12 cases of incident DM over 359.25 person-years, giving 33.4/1000 person-years of follow-up (PYFU) (95% CI: 18.1-56.8/1000), and an rate of incident pre-DM of 212.7/1000 PYFU (95 CI: 164.5-270.9/1000). The two independent factors associated with new-onset DM were having pre-DM at enrolment [aOR = 6.27 (1.89-20.81)] and being established on cART at enrolment [aOR = 12.02 (1.48-97.70)].

CONCLUSIONS

Incidence rates of pre-DM and overt DM among Ghanaian PLWH on cART ranks among the highest in the literature. There is an urgent need for routine screening and a multidisciplinary approach to cardiovascular disease risk reduction among PLWH to reduce morbidity and mortality from the detrimental effects of dysglycaemia.

Care and management of a double burden of chronic diseases: Experiences of patients and perceptions of their healthcare providers

AIM

The increasing burden of comorbid HIV infection and hypertension necessitates a focus on healthcare services providing care for chronic multi-morbidities. The aim of this study was to evaluate the perceptions and experiences of 1) people living with HIV infection and comorbid hypertension, and 2) their healthcare providers, related to their diagnoses and interactions with chronic healthcare services in South Africa.

METHODS

This study comprised quantitative and qualitative arms with a multi-layered approach. We randomly selected 17 public healthcare facilities providing HIV care across Cape Town and surrounding rural municipalities.

RESULTS

Interviews were conducted with clinicians (n = 11), specialised nursing professionals (n = 10), lay counsellors (n = 12), six patients focus groups (n = 35) and 20 in-depth individual patient interviews. There were mixed views on being treated at integrated vs. separate chronic care facilities regarding quality of care and privacy/anonymity. Specialised clinics offered better care for HIV infection while hypertension and other non-communicable diseases were neglected. Privacy about HIV status maybe better maintained in integrated clinics but not if status was disclosed by having the green-coloured HIV treatment card. A single appointment date was considered advantageous as it saved time and money leading to greater compliance; however, waiting times at clinics were longer with perhaps fewer patients seen.

CONCLUSIONS

The mixed reactions elicited to the integration of healthcare services for HIV, hypertension and other non-communicable diseases highlights the complexities involved in implementing such services. Greater human resources with retraining and reskilling of healthcare staff is required for the optimal management of chronic multi-morbidities.

Serum Levels of Fibroblast Growth Factor 23 in People Living with HIV

BACKGROUND

Fibroblast growth factor (FGF) 23 is a well-known phosphaturic hormone produced mainly by bone cells to maintain phosphate and mineral homeostasis. Serum FGF23 levels are elevated in patients with chronic kidney disease (CKD), and elevated FGF23 might increase the risk of cardiovascular disease (CVD). Several reports have documented an increased incidence of risk factors for osteopenia, CKD, and CVD in people living with HIV (PLWH). However, few reports related to FGF23 in PLWH have been published.

METHODS

Male HIV patients who presented to the outpatient clinic of Teikyo University Hospital, Tokyo, Japan, in 2015 and were treated with antiretroviral therapy (ART) for > 6 months were enrolled in the study. In addition to serum FGF23 measurements, the clinical factors assessed included age, ART regimens, and laboratory data. Spearman correlation and multiple regression analysis were performed to determine factors significantly associated with FGF23.

RESULTS

In total, 67 patients were enrolled in the present study. The median age was 43.7 years, the median CD4 count was 529 cells/μL, and the median serum FGF23 level was 36.0 pg/mL. Based on correlation and multiple regression analyses, serum FGF23 levels were significantly correlated with HIV RNA > 50 copies (correlation analysis: t = 3.4259, P = 0.0011 / multiple regression analysis: P = 0.00106) or abacavir (ABC)/lamivudine (3TC) use (t = 2.8618, P = 0.0057 / P = 0.02704).

CONCLUSION

Factors significantly associated with elevated serum FGF23 levels included poor virologic control and ABC/3TC use.

Association of Gut Intestinal Integrity and Inflammation with Insulin Resistance in Adults Living with HIV in Uganda

We conducted a cross-sectional study of 148 HIV+ on HIV antiretroviral therapy and 149 HIV- adults in Mbarara, Uganda, to estimate the association between HIV infection and homeostasis model assessment of insulin resistance (HOMA-IR) using multivariable regression analysis. In addition, we evaluated whether intestinal fatty acid-binding protein (I-FABP), monocyte activation markers soluble (s)CD14 and sCD163, and proinflammatory cytokine interleukin 6 (IL-6) mediated this association. HOMA-IR was greater among HIV+ than HIV- adults [median (interquartile range): 1.3 (0.7-2.5) vs. 0.9 (0.5-2.4); p = 0.008]. In models adjusted for sociodemographic variables, diet, hypertension, and smoking history, HIV infection was associated with 37% [95% confidence intervals (95% CIs): 5-77] greater HOMA-IR compared with HIV- participants. The magnitude of association was greater when I-FABP was included as a covariate although the additive effect was modest (40% CI: 8-82). By contrast adding sCD14 to the model was associated with greater HOMA-IR (59%; 95% CI: 21-109) among HIV+ participants compared with HIV- participants. Among HIV+ participants, greater CD4 nadir was non-significantly associated with greater HOMA-IR (22%; 95% CI: -2 to 52). Each 5-unit increase in body mass index (BMI; 49% greater HOMA-IR; 95% CI: 18-87) and female sex (71%; 95% CI: 17-150) remained associated in adjusted models. In this study of mainly normal-weight Ugandan adults, HIV infection, female sex, and greater BMI were all associated with greater insulin resistance (IR). This association was strengthened modestly after adjustment for sCD14, suggesting possible distinct immune pathways to IR that are independent of HIV or related to inflammatory changes occurring on HIV treatment.

Haptoglobin phenotypes with weak antioxidant capacity increase risk factors of cardiovascular disease in Ghanaian HIV-infected patients on highly active antiretroviral therapy

OBJECTIVE

Highly active antiretroviral therapy (HAART) has considerably reduced HIV/AIDS-related morbidity and mortality; however, the therapy has been associated with the development of cardiovascular disease (CVD), and genetic predisposition factors may aggravate disease outcome. This study was aimed at investigating the relationship between haptoglobin phenotypes and risk factors of CVD in HIV patients.

METHODS

A total of 105 HIV sero-positive patients on HAART and 75 HIV-infected HAART-naïve individuals were enrolled in the study. Socio-demographics and clinical characteristics of the participants were obtained using a well-structured questionnaire. Lipid profile, lactate dehydrogenase (LDH) and haptoglobin (Hp) phenotypes were analysed from serum whiles haemoglobin (Hb) level, CD4⁺ cell count and HIV viral RNA load were determined using whole blood.

RESULTS

Atherogenic index of plasma (AIP) was significantly higher in patients on HAART than the naïve group (P < 0.05). Age, BMI, visceral fat, systolic blood pressure LDH and lipid variables strongly and positively correlated with AIP (P < 0.05), with the exception of HDL-c (P < 0.001) which showed a negative correlation. HAART was associated with hypertension (χ²  = 4.33, P = 0.037), hypercholesterolaemia (χ²  = 10.99, P < 0.001), elevated LDL-c (χ² = 10.30, P < 0.001) and decreased HDL-c (χ²  = 3.87, P = 0.09). Hp2-2 and Hp0 collectively was strongly associated with hypertension (OR = 2.54, P = 0.011), obesity (OR = 5.97, P < 0.001) and hypercholesterolaemia (OR = 2.99, P < 0.001).

CONCLUSION

HIV/AIDS patients on HAART expressing Hp phenotypes with weak antioxidant capacity have an increased risk of developing CVD.

Promoting Cardiovascular Health in Patients Living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Patients living with human immunodeficiency virus/acquired immunodeficiency syndrome (PLWHA) are at increased risk of cardiovascular disease because of advances in human immunodeficiency virus/acquired immunodeficiency syndrome treatment and increased life expectancy. Cardiovascular health promotion in PLWHA includes strategies for risk factor reduction, disease prevention, early detection, and treatment of cardiovascular disease.

Prevalence and correlates of traditional risk factors for cardiovascular disease in a Nigerian ART-naive HIV population: a cross-sectional study

OBJECTIVES

HIV infection environment presents a classic example of the interplay between infectious diseases and non-communicable diseases (NCDs). Traditional cardiovascular disease (CVD) risk factors abound in the HIV population even before initiation of antiretrovirals (ARVs) and predispose them to the development of stroke and myocardial infarction. This work focuses on determining the prevalence of traditional CVD risk factors among ARV-naive HIV individuals in southern Nigeria.

METHODS

This was a cross-sectional study of ARV-naive patients initiating care at the University of Uyo Teaching Hospital HIV clinic cohort to determine the prevalence and correlates of hypertension, diabetes mellitus (DM), obesity and dyslipidaemia.

RESULTS

The sample consisted of 4925 assessed for hypertension, 5223 for obesity, 1818 for DM and 926 for dyslipidaemia. Hypertension prevalence was 26.7% (95% CI 25.5% to 28.0%) with a male preponderance (p=0.02). DM was found in 5.6% (95% CI 4.5% to 6.7%), obesity in 8.3% (95% CI 7.6% to 9.1%) and dyslipidaemia in 29.1% (95% CI 26.1% to 32.1%) with a high prevalence of low high-density lipoprotein-c (42.6%). Hypertension was independently associated with age (OR 1.04 (95% CI 1.03 to 1.05), p<0.001) and body mass index (BMI) (OR 1.06 (95% CI 1.03 to 1.08), p<0.001), obesity with age (OR 1.02 (95% CI 1.01 to 1.03), p<0.001), male gender (OR 0.38 (95% CI 0.29 to 0.49), p<0.001) and CD4 count (OR 2.63 (95% CI 1.96 to 3.53), p<0.001) while dyslipidaemia was associated with BMI (OR 1.05 (95% CI 1.01 to 1.10), p=0.03).

CONCLUSION

The prevalence of traditional CVD risk factors is high in this ART-naive HIV population. An integrated approach of HIV and NCD screening/treatment may be relevant for centres in sub-Saharan Africa.

Prevalence and variables associated with an abnormal ankle-brachial index among patients with human immunodeficiency virus/acquired immunodeficiency syndrome

Objectives The longer survival of patients with human immunodeficiency virus/acquired immunodeficiency syndrome and the introduction of the highly active antiretroviral therapy have increased the number of chronic conditions; among these, cardiovascular diseases. The aim of this study is to determine patient, disease, and factors associated with peripheral arterial disease in a population of patients with human immunodeficiency virus/acquired immunodeficiency syndrome. Methods A prospective nested case-control study of a cohort of patients with human immunodeficiency virus/acquired immunodeficiency syndrome was conducted in a tertiary medical center in Mexico City. A sample size of 206 patients was calculated. Medical history, relevant laboratory data, peripheral arterial exam, and screening ankle-brachial index tests were obtained. Results The prevalence of abnormal ankle-brachial indexes was 20% (42 patients). Patient's mean age was 44 years ±13. The majority (98.5%) were actively receiving highly active antiretroviral therapy; active smoking was reported in 55 (27%), arterial hypertension and type 2 diabetes mellitus were found in 24 (12%) and 22 (11%) patients. Median time from the human immunodeficiency virus diagnosis was eight years (Interquartile range ±11); the mean CD4 count was 481, with a mean viral load of 13,557 copies (SD ± 69025.27) and 1889.18 (SD ± 9052.77) for patients with normal and abnormal ankle-brachial index and a median of 40 (IQ ± 2). Viral load ( p = 0.04) and number of years with human immunodeficiency virus/acquired immunodeficiency syndrome ( p = 0.04) were significantly associated with abnormal ankle-brachial indexes. Conclusions Abnormal ankle-brachial index seems to be more frequent in Mexican patients with human immunodeficiency virus/acquired immunodeficiency syndrome when compared with the general population at the same age. The most important factors associated with arterial disease were the viral load and the number of years with human immunodeficiency virus/acquired immunodeficiency syndrome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02264509.

Hypertension in treated and untreated patients with HIV: a study from 2011 to 2013 at the Jos University Teaching Hospital, Nigeria

Background

Individuals with HIV, especially those on antiretroviral therapy (ART), may have increased risk of hypertension. We investigated the prevalence of hypertension at enrolment and 12 months after commencing ART in a Nigerian HIV clinic.

Methods

Data from patients enrolled for ART from 2011 to 2013 were analysed, including 2310 patients at enrolment and 1524 re-evaluated after 12 months of ART. The presence of hypertension, demographic, clinical and biochemical data were retrieved from standardized databases. Bivariate and logistic regressions were used to identify baseline risk factors for hypertension.

Results

Prevalence of hypertension at enrolment was 19.3% (95% CI 17.6-20.9%), and age (p<0.001), male sex (p=0.004) and body mass index (BMI) (p<0.001) were independent risk factors for hypertension. Twelve months after initiating ART, a further 31% (95% CI 17.6-20.9%) had developed hypertension. Total prevalence at that point was 50.2%. Hypertension among those on ART was associated with age (p=0.009) and BMI (p=0.008), but not with sex. There were no independently significant associations between hypertension and CD4+ counts, viral load or type of ART.

Conclusions

Hypertension is common in HIV infected individuals attending the HIV clinic. Patients initiating ART have a high risk of developing hypertension in the first year of ART. Since BMI is modifiable, life-style advice aimed at weight reduction is strongly advisable.

Prevalence, Risk Factors, and Pathophysiology of Dysglycemia among People Living with HIV in Sub-Saharan Africa

OBJECTIVE

To review available literature on the prevalence, risk factors, pathophysiology, and clinical outcomes of dysglycemia among people living with HIV (PLHIV) in sub-Saharan Africa (SSA).

METHODS

Database search on PUBMED for eligible studies describing the prevalence, risk factors, pathophysiology, or clinical outcomes of dysglycemia in SSA PLHIV.

RESULTS

Prevalence of diabetes mellitus (DM) and pre-DM among SSA PLHIV ranged from 1% to 26% and 19% to 47%, respectively, in 15 identified studies. Older age and an elevated body mass index (BMI) were common risk factors for dysglycemia. Risk factors potentially more specific to PLHIV in SSA included exposure to older-generation thymidine analogues or protease inhibitors, malnutrition at ART initiation, a failure to gain fat mass on treatment, and elevated serum lipids. There is evidence of higher nephropathy and neuropathy rates among PLHIV in SSA with comorbid DM compared to HIV-negative individuals with DM.

CONCLUSION

There is a need for longitudinal studies to enhance understanding of the risk factors for dysglycemia among PLHIV in SSA, further research into optimal therapies to reduce pre-DM progression to DM among SSA PLHIV, and studies of the burden and phenotype of diabetic complications and other health outcomes among PLHIV with comorbid DM in SSA.

Incidence and risk factors for hypertension among HIV patients in rural Tanzania - A prospective cohort study

INTRODUCTION

Scarce data are available on the epidemiology of hypertension among HIV patients in rural sub-Saharan Africa. We explored the prevalence, incidence and risk factors for incident hypertension among patients who were enrolled in a rural HIV cohort in Tanzania.

METHODS

Prospective longitudinal study including HIV patients enrolled in the Kilombero and Ulanga Antiretroviral Cohort between 2013 and 2015. Non-ART naïve subjects at baseline and pregnant women during follow-up were excluded from the analysis. Incident hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg on two consecutive visits. Cox proportional hazards models were used to assess the association of baseline characteristics and incident hypertension.

RESULTS

Among 955 ART-naïve, eligible subjects, 111 (11.6%) were hypertensive at recruitment. Ten women were excluded due to pregnancy. The remaining 834 individuals contributed 7967 person-months to follow-up (median 231 days, IQR 119-421) and 80 (9.6%) of them developed hypertension during a median follow-up of 144 days from time of enrolment into the cohort [incidence rate 120.0 cases/1000 person-years, 95% confidence interval (CI) 97.2-150.0]. ART was started in 630 (75.5%) patients, with a median follow-up on ART of 7 months (IQR 4-14). Cox regression models identified age [adjusted hazard ratio (aHR) 1.34 per 10 years increase, 95% CI 1.07-1.68, p = 0.010], body mass index (aHR per 5 kg/m2 1.45, 95% CI 1.07-1.99, p = 0.018) and estimated glomerular filtration rate (aHR < 60 versus ≥ 60 ml/min/1.73 m2 3.79, 95% CI 1.60-8.99, p = 0.003) as independent risk factors for hypertension development.

CONCLUSIONS

The prevalence and incidence of hypertension were high in our cohort. Traditional cardiovascular risk factors predicted incident hypertension, but no association was observed with immunological or ART status. These data support the implementation of routine hypertension screening and integrated management into HIV programmes in rural sub-Saharan Africa.

Increased risk of dysglycaemia in South Africans with HIV; especially those on protease inhibitors

AIMS

To compare dysglycaemia prevalence (impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes) in HIV-infected persons, stratified by antiretroviral therapy (ART), with a community-based survey (CBS) in Cape Town, South Africa.

METHODS

Three groups of HIV-infected adults without known diabetes were conveniently sampled from community healthcare centres; ART-naïve, first-line ART (non-nucleoside reverse transcriptase inhibitor (NNRTI) plus dual NRTIs), and second-line ART (lopinavir/ritonavir-boosted protease inhibitor plus dual NRTIs). The CBS recruited a representative cross-sectional sample from urban townships. Participants reporting ART use or known diabetes were excluded. All participants underwent oral glucose tolerance testing. Multiple logistic regression determined independent associations with dysglycaemia.

RESULTS

The samples comprised ART-naïve, first-line ART, second-line ART and CBS participants (n=393, 439, 108 and 880, respectively). Mean age was 34-40years. Dysglycaemia prevalence was as follows: CBS 18.0%, ART-naïve 21.6%, first-line ART 26.0% and second-line ART 37.0%. Diabetes was similar across groups, but IGT was 3-4-fold higher in second-line ART and CBS compared with ART-naïve and first-line ART groups. In contrast, IFG was 14.3-21.2% across HIV groups but only 1.5% in the CBS. Increased risk of dysglycaemia was associated with older age, female gender, and HIV status (ART-naïve: OR 2.31, 95% CI 1.65-3.24; first-line ART: OR 2.47, 95% CI 1.80-3.38; second-line ART: OR 4.10, 95% CI 2.54-6.61). Diabetes family history and central obesity were not related to dysglycaemia.

CONCLUSIONS

In view of the increased risk of dysglycaemia in HIV-infected participants, screening for diabetes should be instituted in ART programmes.

The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children

INTRODUCTION

As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment.

METHODS

We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities.

RESULTS AND DISCUSSION

Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few.

CONCLUSIONS

Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.

Risk Factors of Cardiovascular Diseases in HIV/AIDS Patients on HAART

BACKGROUND

The introduction and widespread use of combination antiretroviral therapy referred to as highly active antiretroviral therapy (HAART) in the mid 1990's, has led HIV-infected individuals to experience a dramatic decline in immunodeficiency-related events and death. There is growing concern on metabolic complications associated with HIV and HAART which may increase cardiovascular risk and disease. The aim of this study was to investigate the cardiovascular risk profile of HIV/AIDS patients receiving HAART and those not receiving HAART at HIV/AIDS treatment centres in the South West Region of Cameroon.

METHODS

Consenting participants, who had been receiving HAART, were compared with HAART naive participants. A questionnaire was administered; anthropometric and blood pressure measurements were recorded under standard conditions. Blood samples were obtained for the determination of plasma glucose and lipid levels.

RESULTS

Two hundred and fifteen participants were recruited, 160 (74.4%) were on HAART and 55 (25.6%) were HAART naive. Among the individual lipid abnormalities, increased total cholesterol was the most prevalent (40.0%). Participants on HAART were significantly about 8 times at risk of developing hypercholesterolemia when compared to the HAART inexperienced group (OR 8.17; 95% CI: 3.31-20.14; p<0.001). Hypertension had a prevalence of 25.6% (95% CI: 15.3%-35.9%) and was about 2 times significantly higher in the HAART treated than the HAART untreated group (p=0.033). The prevalence of low HDL-c was significantly higher in males (24.1%) compared to females (11.2%) (p=0.0196). Many females (27.3%) were obese compared to males (7.4%) (p=0.0043). HAART use and treatment duration of more than five years were significantly associated with higher prevalence of CVD risk factors.

CONCLUSION

HAART treatment was associated with significantly higher prevalence of hypercholesterolemia, increased LDL-c and hypertension, hence the risk of cardiovascular diseases.

Association of hypertension and obesity with HIV and antiretroviral therapy in a rural tertiary health center in Nigeria: a cross-sectional cohort study

Background

There are few studies from Nigeria and Africa regarding the contribution of obesity and hypertension to cardiovascular risk in HIV-infected patients. This study investigates the prevalence of hypertension and obesity and their association with HIV infection and antiretroviral treatment (ART).

Methods

We conducted a cross-sectional cohort study in a rural tertiary health center in Nigeria. The data collected included demographic variables, blood pressure, body mass index (BMI), monthly income, educational attainment, HIV status and ART treatment, duration of treatment, and CD4 T-lymphocyte count.

Results

A total of 403 participants met the inclusion criteria. There were 153 (38.0%) HIV-negative subjects (42.5% male, 57.5% female; mean age: 35.5±7.6 years), 120 (29.8%) HIV-positive drug-naïve subjects (42.5% male, 57.5% female; mean age: 36.5±9.1 years), and 130 (32.2%) HIV-positive subjects taking antiretroviral drugs (33.1% male, 66.9% female; mean age: 38.6±8.0 years). The prevalence of hypertension was 13.7% in HIV-negative subjects, 19.0% in HIV-positive drug-naïve subjects, and 12.3% in HIV-positive ART subjects. The prevalence of obesity was 15.9% in the HIV-negative group, 3% in the HIV-positive drug-naïve group, and 8% in the HIV-positive ART group. Multivariate regression analysis showed no relationship between hypertension and HIV status (P=0.293) or ART status (P=0.587). In contrast, BMI showed a strong relationship with HIV status (odds ratio: 0.281; 95% confidence interval: 0.089–0.884; P=0.030) but not with ART status (P=0.593). BMI was a significant predictor of hypertension.

Conclusion

HIV or ART status was not associated with hypertension. HIV infection was associated with a lower BMI, and a lower prevalence of obesity compared with HIV-negative subjects.

A comparison of the predicted risk for cardiovascular disease between HIV-infected and uninfected persons in Korea

BACKGROUND

The introduction of highly active antiretroviral therapy (HAART) has extended the life expectancy of persons infected with the human immunodeficiency virus type 1 (HIV-1). However, cardiovascular disease (CVD) is currently an increasing concern for HIV-infected persons.

METHODS

We conducted a cross-sectional case-control study to evaluate and compare the 10-y cardiovascular risk of HIV-infected Koreans who had been receiving HAART for over 6 months and age- and sex-matched uninfected persons who visited a health promotion center, by calculating Framingham risk scores (FRS).

RESULTS

The average 10-y risk for cardiovascular events (FRS) was 7.07% (2-45) in the HIV group and 6.87% (1-37) in the control group (p = 0.77), corresponding to the very low risk group. Among HIV patients, the FRS was above 10% (low to moderate cardiovascular risk) in 19.9% of the patients, and above 20% (high risk) in 1.7% of the patients. In the healthy control group, the FRS was above 10% in 16.8% and above 20% in 2.7% (p = 0.57). The FRS was not significantly different for HIV-infected patients treated with protease inhibitor (PI)-based HAART and those treated with non-nucleoside reverse transcriptase inhibitor (NNRTI)-based HAART (7.26 ± 6.3 and 6.81 ± 4.4, respectively, p = 0.69).

CONCLUSIONS

The predicted cardiovascular risk of HIV-infected Koreans on HAART by FRS equation was low and similar to that of age- and sex-matched healthy control persons. However, the possibility remains that actual cardiovascular events could be underestimated. The next step for predicting the cardiovascular risk is to calculate the Data Collection of Adverse Events of Anti-HIV Drugs (D:A:D) equation risks.

A literature review on cardiovascular risk in human immunodeficiency virus-infected patients: implications for clinical management

Introduction

In recent years, there has been growing concern about an increasing rate of cardiovascular diseases in human immunodeficiency virus-infected patients, which could be associated with side effects of highly active antiretroviral therapy. It is likely that the metabolic disorders related to anti-human immunodeficiency virus treatment will eventually translate into a increased cardiovascular risk in patients submitted to such regimens.

Objective

To evaluate if human immunodeficiency virus-infected patients receiving highly active antiretroviral therapy are at higher risk of cardiovascular diseases than human immunodeficiency virus infected patients not receiving highly active antiretroviral therapy, or the general population.

Research design and methods

We conducted a computer-based search in representative databases, and also performed manual tracking of citations in selected articles.

Result

The available evidence suggests an excess risk of cardiovascular events in human immunodeficiency virus-infected persons compared to non-human immunodeficiency virus infected individuals. The use of highly active antiretroviral therapy is associated with increased levels of total cholesterol, triglycerides, low-density lipoprotein and morphological signs of cardiovascular diseases. Some evidence suggested that human immunodeficiency virus-infected individuals on highly active antiretroviral therapy regimens are at increased risk of dyslipidemia, ischemic heart disease, and myocardial infarction, particularly if the highly active antiretroviral therapy regimen contains a protease inhibitor.

Conclusion

Physicians must weigh the cardiovascular risk against potential benefits when prescribing highly active antiretroviral therapy. Careful cardiac screening is warranted for patients who are being evaluated for, or who are receiving highly active antiretroviral therapy regimens, particularly for those with known underlying cardiovascular risk factors. A better understanding of the molecular mechanisms responsible for increased risk of cardiovascular diseases in human immunodeficiency virus-infected patients will lead to the discovery of new drugs that will reduce cardiovascular risk in human immunodeficiency virus-infected patients receiving highly active antiretroviral therapy.

Physical fitness in children infected with the human immunodeficiency virus: associations with highly active antiretroviral therapy

Obesity, sedentary lifestyles, and antiretroviral therapies may predispose HIV-infected children to poor physical fitness. Estimated peak oxygen consumption (VO(2) peak), maximal strength and endurance, and flexibility were measured in HIV-infected and uninfected children. Among HIV-infected children, anthropometric and HIV disease-specific factors were evaluated to determine their association with VO(2) peak. Forty-five HIV-infected children (mean age 16.1 years) and 36 uninfected children (mean age 13.5 years) participated in the study. In HIV-infected subjects, median viral load was 980 copies/ml (IQR 200-11,000 copies/ml), CD4% was 28% (IQR 15-35%), and 82% were on highly active antiretroviral therapy (HAART). Compared to uninfected children, after adjusting for age, sex, race, body fat, and siblingship, HIV-infected children had lower VO(2) peak (25.92 vs. 30.90 ml/kg/min, p<0.0001), flexibility (23.71% vs. 46.09%, p=0.0003), and lower-extremity strength-to-weight ratio (0.79 vs. 1.10 kg lifted/kg of body weight, p=0.002). Among the HIV-infected children, a multivariable analysis adjusting for age, sex, race, percent body fat, and viral load showed VO(2) peak was 0.30 ml/kg/min lower per unit increase in percent body fat (p<0.0001) and VO(2) peak (SE) decreased 29.45 (± 1 .62), 28.70 (± 1.87), and 24.09 (± 0.75) ml/kg/min across HAART exposure categories of no exposure, <60, and ≥ 60 months, respectively (p<0.0001). HIV-infected children had, in general, lower measures of fitness compared to uninfected children. Factors negatively associated with VO(2) peak in HIV-infected children include higher body fat and duration of HAART ≥ 60 months. Future studies that elucidate the understanding of these differences and mechanisms of decreased physical fitness should be pursued.

Double product and end-organ damage in African and Caucasian men: the SABPA study

BACKGROUND

Increasing urbanisation in sub-Saharan African countries is causing a rapid increase in cardiovascular disease. Evidence suggests that Africans have higher blood pressures and a higher prevalence of hypertension-related cardiovascular morbidity and mortality, compared to Caucasians. We investigated double product (systolic blood pressure × heart rate), a substantial measure of cardiac workload, as a possible cardiovascular risk factor in African and Caucasian men.

MATERIAL AND METHODS

The study consisted of 101 urbanised African and 101 Caucasian male school teachers. We measured 24h ambulatory blood pressure and the carotid cross-sectional wall area, and determined left ventricular hypertrophy electrocardiographically by means of the Cornell product. Urinary albumin and creatinine were analysed to obtain the albumin-to-creatinine ratio.

RESULTS

Africans had higher 24h, daytime and nighttime systolic- and diastolic blood pressure, heart rate and resultant double product compared to the Caucasians. In addition, markers of end-organ damage, albumin-to-creatinine ratio and left ventricular hypertrophy were higher in the Africans while cross-sectional wall area did not differ. In Africans after single partial and multiple regression analysis, 24h systolic blood pressure, but not double product or heart rate, correlated positively with markers of end-organ damage (cross-sectional wall area: β=0.398, P=0.005; left ventricular hypertrophy: β=0.455, P<0.001; albumin-to-creatinine ratio: β=0.280, P=0.012). No associations were evident in Caucasian men.

CONCLUSIONS

Double product may not be a good marker of increased cardiovascular risk when compared to systolic blood pressure in African and Caucasian men.

Hypertension and obesity as cardiovascular risk factors among HIV seropositive patients in Western Kenya

BACKGROUND

There is increased risk of cardiovascular disease among HIV seropositive individuals. The prevalence of HIV is highest in sub-Saharan Africa; however, HIV-related cardiovascular risk research is largely derived from developed country settings. Herein, we describe the prevalence of hypertension and obesity in a large HIV treatment program in Kenya.

METHODS

We performed a retrospective analysis of the electronic medical records of a large HIV treatment program in Western Kenya between 2006 and 2009. We calculated the prevalence of hypertension and obesity among HIV+ adults as well as utilized multiple logistic regression analyses to examine the relationship between clinical characteristics, HIV-related characteristics, and hypertension.

RESULTS

Our final sample size was 12,194. The median systolic/diastolic blood pressures were similar for both sexes (male: 110/70 mmHg, female: 110/70 mmHg). The prevalence of hypertension among men and women were 11.2% and 7.4%, respectively. Eleven percent of men and 22.6% of women were overweight/obese (body mass index ≥25 kg/m(2)). Ordinal logistic regression analyses showed that overweight/obesity was more strongly associated with hypertension among HIV+ men (OR 2.41, 95% CI 1.88-3.09) than a higher successive age category (OR 1.62, 95% CI 1.40-1.87 comparing 16-35, 36-45 and >45 years categories). Among women, higher age category and overweight/obesity were most strongly associated with hypertension (age category: OR 2.21, 95% CI 1.95-2.50, overweight/obesity: OR 1.80, 95% CI 1.50-2.16). Length of time on protease inhibitors was not found to be related to hypertension for men (OR 1.62, 95% CI 0.42-6.20) or women (OR 1.17, 95% CI 0.37-2.65) after adjustment for CD4 count, age and BMI.

CONCLUSION

In Western Kenya, there is a high prevalence of hypertension and overweight/obesity among HIV+ patients with differences observed between men and women. The care of HIV+ patients in sub-Saharan Africa should also include both identification and management of associated cardiovascular risk factors.

Risk of heart failure with human immunodeficiency virus in the absence of prior diagnosis of coronary heart disease

BACKGROUND

Whether human immunodeficiency virus (HIV) infection is a risk factor for heart failure (HF) is not clear. The presence of coronary heart disease and alcohol consumption in this population may confound this association.

METHODS

To determine whether HIV infection is a risk factor for incident HF, we conducted a population-based, retrospective cohort study of HIV-infected and HIV-uninfected veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC) and the 1999 Large Health Study of Veteran Enrollees (LHS) from January 1, 2000, to July 31, 2007.

RESULTS

There were 8486 participants (28.2% HIV-infected) enrolled in the VACS-VC who also participated in the 1999 LHS. During the median 7.3 years of follow-up, 286 incident HF events occurred. Age- and race/ethnicity-adjusted HF rates among HIV-infected and HIV-uninfected veterans were 7.12 (95% confidence interval [CI], 6.90-7.34) and 4.82 (95% CI, 4.72-4.91) per 1000 person-years, respectively. Compared with HIV-uninfected veterans, those who were HIV infected had an increased risk of HF (adjusted hazard ratio [HR], 1.81; 95% CI, 1.39-2.36). This association persisted among veterans who did not have a coronary heart disease event or a diagnosis related to alcohol abuse or dependence before the incident HF event (adjusted HR, 1.96; 95% CI, 1.29-2.98). Compared with HIV-uninfected veterans, those who were HIV infected with a baseline Human immunodeficiency virus 1 (HIV-1) RNA level of 500 or more copies/mL had a higher risk of HF (adjusted HR, 2.28; 95% CI, 1.57-3.32), while those with baseline and a recent HIV-1 RNA level less than 500 copies/mL did not (adjusted HR, 1.10; 95% CI,  0.64-1.89; P < .001 for comparison between high and low HIV-1 RNA groups).

CONCLUSIONS

Our data suggest that HIV infection is a risk factor for HF. Ongoing viral replication is associated with a higher risk of developing HF.

Sigmoid Th17 populations, the HIV latent reservoir, and microbial translocation in men on long-term antiretroviral therapy

OBJECTIVE

Th17 cells play an important role in mucosal defence and repair and are highly susceptible to infection by HIV. Antiretroviral therapy (ART) suppresses HIV viremia and can restore CD4(+) numbers in the blood and gastrointestinal mucosa, but the resolution of systemic inflammation and gut microbial translocation is often incomplete. We hypothesized that this might relate to persistent dysregulation of gut CD4(+) Th17 subsets.

METHODS

Blood and sigmoid biopsies were collected from HIV-uninfected men, chronically HIV-infected, ART-naive men, and men on effective ART for more than 4 years. Sigmoid provirus levels were assayed blind to participant status, as were CD4(+) Th17 subsets, systemic markers of microbial translocation, and cellular immune activation.

RESULTS

There was minimal CD4(+) Th17 dysregulation in the blood until later stage HIV infection, but gastrointestinal Th17 depletion was apparent much earlier, along with increased plasma markers of microbial translocation. Plasma lipopolysaccharide (LPS) remained elevated despite overall normalization of sigmoid Th17 populations on long-term ART, although there was considerable interindividual variability in Th17 reconstitution. An inverse correlation was observed between plasma LPS levels and gut Th17 frequencies, and higher plasma LPS levels correlated with an increased gut HIV proviral reservoir.

CONCLUSION

Sigmoid Th17 populations were preferentially depleted during HIV infection. Despite overall CD4(+) T-cell reconstitution, sigmoid Th17 frequencies after long-term ART were heterogeneous and higher frequencies were correlated with reduced microbial translocation.