The effect of HIV infection, antiretroviral therapy on carotid intima-media thickness: A systematic review and meta-analysis

Evaluation of Myo-Intimal Media Thickness and Atheromatous Plaques in People Living with HIV from the Archiprevaleat Cohort vs. HIV-Negative Subjects

BACKGROUND

Antiretroviral therapy has allowed a clear improvement in prognosis for HIV patients, but metabolic problems, such as dyslipidemia, remain. This can lead to the development of atheromatous plaques. Our study aims to evaluate whether HIV-positive (HIV+) patients show higher myo-intimal media thickness (IMT) and atheromatous plaques compared to HIV-negative (HIV-) patients.

METHODS

To evaluate the association between HIV infection in experienced patients and vascular pathology, we performed a cross-sectional study, observing 1006 patients, 380 HIV+ enrolled in the Archiprevaleat cohort, and 626 HIV- as a control group. All patients underwent a Doppler scan of the supra-aortic vessels. We compared the prevalence of IMT > 1.0 mm and plaques in the two groups.

RESULTS

Patients in the HIV+ group were younger than those in the HIV- group, with a lower prevalence of hypertension and diabetes and higher dyslipidemia. The prevalence of plaques in strata of age was higher in the HIV+ group than in the HIV- group and was associated with the length of ART exposure.

CONCLUSIONS

Our cross-sectional, retrospective study shows that HIV+ experienced patients are at greater risk of IMT and atheromatous plaques compared to HIV-. The risk is associated with being HIV+ and with the length of ART exposure. This finding may be useful in preventing cardiovascular risk.

Changes in Cerebrospinal Fluid, Liver and Intima-media-thickness Biomarkers in Patients with HIV-associated Neurocognitive Disorders Randomized to a Less Neurotoxic Treatment Regimen

The prevalence of neurocognitive impairment in people living with HIV is estimated between 30 and 50%. The pathogenesis of HIV-associated neurocognitive disorders is complex and multifactorial. Aim of the study was to measure the change in CSF biomarkers, Fibroscan and IMT measurements in PLWH with HAND randomized to a less neurotoxic regimen, or continuing their treatment. Adult patients with HAND were screened and enrolled if presenting no major resistance associated mutations, no HIV viral replication, not on efavirenz or darunavir, with R5-tropic HIV and without major confounding conditions. Lumbar puncture, IMT and Fibroscan measurements were performed. After 1:1 randomization to a less neurotoxic regimen consisting of darunavir/cobicistat plus emtricitabine plus maraviroc, or mantaining actual care, tests were repeated after 24 weeks: CSF biomarkes (HIV RNA, tau, p-tau, Beta-amyloid1-42, S100Beta and neopterin) were included. Non-parametric tests (Mann-Whitney and Wilcoxon's) were used. 28 participants completed the study. Male and European ancestry were prevalent; median age was 55 years (51-60). All patients were virally suppressed; median CD4 + count was 626 cell/uL (469-772). Baseline characteristics were similar between the study arms. A significant decrease in CSF p-tau and an increase in CSF neopterin and NFL were observed. We observed a significant reduction in liver stiffness at W24. Despite a small sample size we observed changes in neuromarkers and in hepatic stiffness in patients randomized to the experimental arm. We observed changes in CSF biomarkers (lower phosphorylated-tau and higher neopterin and NFL) that need to be replicated in large cohorts. Subclinical neurotoxicity may be observed in patients with HAND and warrants prospective studies.

Carotid Ultrasound Abnormalities of People Living With HIV in Kunming, China: Multiple Correspondence Analysis Approach to Identify Influencing Factors

BACKGROUND

With the use of antiretroviral therapy (ART), the life expectancy of people living with HIV (PLWH) is gradually increasing, but subclinical atherosclerotic cardiovascular disease is becoming increasingly common in PLWH.

METHODS

We obtained data from 326 PLWH. Based on the results of carotid ultrasonography, we divided patients into normal and abnormal carotid ultrasound groups and performed the χ2 test and multiple correspondence analysis (MCA) to determine the influencing factors of abnormal carotid ultrasound.

RESULTS

Among the 326 PLWH, the overall abnormality rate of carotid ultrasound was 31.9% (104/326). MCA showed that carotid ultrasound abnormalities were markedly more common in patients with age (non-youth), BMI ≥24.0 kg/m2, hypertension, diabetes, hyperlipidemia, ART treatment ≥5 years, and CD4+T lymphocyte count <200/μL.

CONCLUSION

Carotid ultrasound is more likely to be abnormal when PLWH have higher age, BMI ≥24.0 kg/m2, hypertension, diabetes, hyperlipidemia, a longer course of ART, and a low CD4+ T lymphocyte count.

Echocardiographic assessment of left cardiac structure and function in antiretroviral therapy (ART)-naïve people living with HIV/AIDS

BACKGROUND

Patients with human immunodeficiency virus (HIV) are at a significantly higher risk of cardiovascular disease (CVD) compared to HIV-negative people. Left heart dysfunction is the most common cardiac complication in people living with HIV/acquired immune deficiency syndrome (PLWHA), and diastolic dysfunction is an important predictor of cardiovascular events. The aims of this study were (1) to detect changes in left cardiac structure and function in antiretroviral therapy (ART)-naive PLWHA using echocardiography; and (2) to investigate the risk factors for the development of left ventricular diastolic dysfunction (LVDD) in ART-naive PLWHA.

METHODS

We retrospectively included 105 ART-naïve PLWHA and included 90 healthy subjects as controls to compare the differences in left heart structure and function between the two groups. Univariate and multifactorial logistic regression were employed to explore the risk factors of the development of LVDD in ART-naive PLWHA.

RESULTS

The left ventricular end-diastolic internal diameter (LVEDD), left ventricular mass index (LVMI), and left atrial volume index (LAVI) were significantly greater in PLWHA than in controls (p < .05). The E/A ratio, lateral e' velocity, and mitral deceleration time were significantly lower in PLWHA than in controls (p < .05). Average E/e' ratio was significantly higher in PLWHA than in controls (p < .05). Left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) were not significantly different between PLWHA and controls (p > .05). Multifactorial logistic regression analysis showed that age, body mass index (BMI), and CD4⁺ count <200 cells/μL were independent risk factors for LVDD in ART-naive PLWHA (OR = 1.781, 1.228, 3.683, p < .05).

CONCLUSIONS

Left ventricular systolic function did not differ between PLWHA and controls, and left ventricular diastolic function was lower in PLWHA than in controls. Age, BMI, and CD4⁺ count were independent factors affecting LVDD in ART-naive PLWHA.

Cardiovascular disease risk in women living with HIV

PURPOSE OF REVIEW

To synthesize current evidence on the impact of cardiovascular disease among women living with HIV (WLWH) with a particular focus on disease prevalence, mechanisms and prevention.

RECENT FINDINGS

HIV-related cardiovascular disease risk is 1.5-fold to 2-fold higher for women than for men. Mechanisms of enhanced risk are multifactorial and include reinforcing pathways between traditional risk factors, metabolic dysregulation, early reproductive aging and chronic immune activation. These pathways influence both the presentation of overt syndromes of myocardial infarction, stroke and heart failure, as well as subclinical disease, such as microvascular dysfunction and cardiac fibrosis. Cardiovascular disease, therefore, remains a consistent threat to healthy aging among WLWH.

SUMMARY

Although no specific prevention strategies exist, patient-centered risk mitigation approaches that are adaptable to the needs of aging individuals are essential to combat disparities in cardiovascular outcomes among WLWH. Further research into the optimal prevention approach for CVD among WLWH, particularly for women living in under-resourced health systems, is needed.

Evaluation of Intima-Media Thickness and Arterial Stiffness as Early Ultrasound Biomarkers of Carotid Artery Atherosclerosis

Carotid atherosclerosis is a major and potentially preventable cause of ischemic stroke. It begins early in life and progresses silently over the years. Identification of individuals with subclinical atherosclerosis is needed to initiate early aggressive vascular prevention. Although carotid plaque appears to be a powerful predictor of cardiovascular risk, carotid intima-media thickness (CIMT) and arterial stiffness can be detected at the initial phases and, therefore, they are considered important new biomarkers of carotid atherosclerosis. There is a well-documented association between CIMT and cerebrovascular events. CIMT provides a reliable marker in young people, in whom plaque formation or calcification is not established. However, the usefulness of CIMT measurement in the improvement of risk cardiovascular models is still controversial. Carotid stiffness is also significantly associated with ischemic stroke. Carotid stiffness adds value to the existing risk prediction based on Framingham risk factors, particularly individuals at intermediate cardiovascular risk. Carotid ultrasound is used to assess carotid atherosclerosis. During the last decade, automated techniques for sophisticated analysis of vascular mechanics have evolved, such as speckle tracking, and new methods based on deep learning have been proposed with promising outcomes. Additional research is needed to investigate the imaging-based cardiovascular risk prediction of CIMT and stiffness.

Age-related differences in the vascular function and structure of South Africans living with HIV

Background

As the life expectancy of people living with the HIV increases because of antiretroviral treatment (ART), their risk for vascular co-morbidities and early vascular ageing (EVA) also increases.

Objective

We aimed to investigate whether HIV infection relates to vascular structure and function in black South African adults and whether this relationship is age dependent.

Method

This cross-sectional study carried out in urban and rural areas of North West province, South Africa, included 572 age- and sex-matched people living with HIV (PLWH) and without HIV. Participants from the EndoAfrica study and PURE study were stratified according to tertiles of age. Measures of vascular structure (carotid intima-media thickness) and function (carotid-femoral pulse wave velocity, central systolic blood pressure, central pulse pressure and pulse pressure amplification) were determined.

Results

Blood pressure measures were lower in PLWH compared with their controls (all P ≤ 0.001), especially in the younger and middle-aged groups (all P ≤ 0.031), whilst vascular measures did not differ (all P ≥ 0.611). In multivariate linear regression analyses, vascular measures were not associated with a HIV- positive status in either the total or any of the age groups.

Conclusion

Black South Africans living with HIV have a less adverse blood pressure profile than their counterparts without HIV. The HIV-positive status was not associated with measures of vascular structure or function in any age group. The results suggest that HIV does not contribute to EVA in this population; however, further longitudinal investigation is warranted.

Cardiovascular toxicity of contemporary antiretroviral therapy

PURPOSE OF REVIEW

HIV treatment has evolved since the introduction of antiretroviral therapy (ART) in the 1990s. Earlier treatment strategies, and the introduction of integrase inhibitors in preferred first-line ART have fundamentally changed cardiovascular side effects due to HIV infection and ART. This review provides an update on cardiovascular toxicity of contemporary ART.

RECENT FINDINGS

Cardiovascular disease (CVD) risk, including heart failure, is still increased in people living with HIV (PLWH). Exposure to older antiretrovirals, including stavudine and zidovudine, still impact on CVD risk through persistent changes in body fat distribution years after discontinuation. Protease inhibitors (PI) and efavirenz have associated metabolic disturbances and increased risk of CVD, although use is decreasing worldwide. Integrase inhibitors and CCR5 antagonists seem to have negligible immediate CVD toxicity. Weight gain on newer antiretrovirals including integrase inhibitors is a reason for concern.

SUMMARY

CVD risk should be monitored carefully in PLWH who were exposed to first generation ART, efavirenz or to PIs. Registries should capture ART use and CVD events to stay informed on actual clinical risk in the current era of rapid initiation on integrase inhibitor-based ART.

Subclinical atherosclerosis and immune activation in young HIV-infected patients with telomere shortening

Background: To date, available data on premature aging in young HIV-infected adults are scarce and no reports offer comprehensive assessment of telomere shortening (TS) in relation to subclinical atherosclerosis (SCA). In this study, we investigate if telomere shortening and immune activation markers are associated with SCA, which is one of the main degenerative diseases in young HIV-infected adults.

Methods: A descriptive cross-sectional study was carried out in 149 HIV-infected patients on stable antiretroviral regimen (ART). Carotid intima-media thickness (cIMT) was estimated by carotid ultrasound. Quantitative singleplex PCR was performed to evaluate TS. The expression of activation/senescence markers was evaluated by multiparametric flow cytometry.

Results: TS was observed in 73 patients (49%). Higher cIMT was observed in patients with TS than those without it (0.86 vs. 0.80 mm; p=0.041). Patients under the age of 50 (defined as young adults) with TS showed higher absolute numbers of activated lymphocyte T cells CD8+CD38+ (3.94 vs. 2.34 cell/μl; p=0.07) and lymphocyte B cells CD19+CD38+ (3.07 vs. 2.10 cell/μl; p=0.004) compared to those without TS. In the multivariate analysis, the only factor independently associated with TS was the absolute number of lymphocyte T cells CD8+CD38+ T cells (OR = 1.18; 95%-CI = 1.00-1.39; p = 0.05).

Conclusion: Young HIV-infected adults show premature biological aging with accentuated immune activation. Chronic inflammation with excessive T-cells activation could be associated to TS, premature aging, and SCA in young HIV-infected adults.

Prevention of stroke in people living with HIV

In the era of effective antiretroviral therapy (ART), HIV has become a manageable disease marked by an elevated risk of non-AIDS-related comorbidities, including stroke. Rates of stroke are higher in people living with HIV (PLWH) compared with the general population. Elevated stroke risk may be attributable to traditional risk factors, HIV-associated chronic inflammation and immune dysregulation, and possible adverse effects of long-standing ART use. Tailoring stroke prevention strategies for PLWH requires knowledge of how stroke pathogenesis may differ from non-HIV-associated stroke, knowledge of long-term stroke outcomes in HIV, and accurate stroke risk assessment tools. As a result, the approach to primary and secondary stroke prevention in PLWH relies heavily on guidelines developed for the general population, with an emphasis on optimization of traditional vascular risk factors and early initiation of ART. This review summarizes existing evidence on HIV-associated stroke mechanisms and considerations for stroke prevention for PLWH.