Screening and management of cardiovascular disease in Australian adults with HIV infection

Integrating hypertension detection and management in HIV care in South Africa: protocol for a stepped-wedged cluster randomized effectiveness-implementation hybrid trial

BACKGROUND

HIV clinical guidelines recommend hypertension detection and management to lower cardiovascular disease risk, but these have not been effectively implemented for people living with HIV (PWH). Addressing this implementation gap requires community-engaged implementation studies focused on addressing implementation barriers specific to the HIV care context.

METHODS

This protocol describes a type 2 effectiveness-implementation hybrid study conducted in nine primary care clinics in Johannesburg. The study will evaluate the effect of implementation strategies on guideline-recommended blood pressure assessment and management in HIV clinics and the effects of assessment/management on patient blood pressure. A stepped-wedge, cluster randomized study design was used to randomize clinics to the time at which they receive the implementation strategies and patient intervention. The implementation strategies tested include identifying and preparing care champions, changing record systems, conducting ongoing training, providing audit and feedback, and changing the physical structure/equipment. The patient intervention tested includes detection of elevated blood pressure, educational materials, lifestyle modification advice, and medication where needed. Implementation outcomes include adoption, fidelity (co-primary outcome), cost, and maintenance of the blood pressure assessment protocol in participating clinics, while patient outcomes include reach, effectiveness (co-primary outcome), and long-term effects of the intervention on patient blood pressure. These will be assessed via direct observation, study records, staff logs, medical chart reviews, and patient and healthcare worker surveys. To examine effects on the implementation (intervention fidelity) and effectiveness (patient blood pressure changes) co-primary outcomes, we will use the standard Hussey and Hughes model for analysis of stepped-wedge designs which includes fixed effects for both interventions and time periods, and a random effect for sites. Finally, we will examine the costs for the implementation strategies, healthcare worker time, and patient-facing intervention materials, as well as the cost-effectiveness and cost-utility of the intervention using study records, patient surveys, and a time and motion assessment.

DISCUSSION

This study will address knowledge gaps around implementation of cardiovascular disease preventive practices in HIV care in South Africa. In doing so, it will provide a dual opportunity to promote evidence-based care in the South African HIV care context and help refine implementation research methods to better serve HIV populations globally.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05846503. Registered on May 6, 2023. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05846503 .

Integration of Primary Preventive Care of Cardiovascular Disease in a Retroviral Clinic in an adult retroviral clinic in Ibadan: A retrospective study

BACKGROUND

A consequence of improved survival of people living with human immunodeficiency virus (HIV) (PLHIV) is an aging population with an increased risk of developing atherosclerotic cardiovascular diseases (ASCVDs). International guidelines recommend primary preventive strategies which should be integrated into routine care of PLHIV.

AIMS

This study audited the ASCVD preventive practices offered to PLHIV at the adult antiretroviral clinic in Ibadan.

METHODS

This was a retrospective review of clinical records of all persons who were recruited into the antiretroviral therapy clinic between January 1 and December 31, 2018. Cardiovascular disease (CVD) preventive practices were audited against recommendations of the American Heart Association for PLHIV.

RESULTS

The records of 568 persons with a mean (standard deviation) age of 39.95 (11.77) years were reviewed. There were 365 (64.26%) females and 203 (35.74%) males. Only 364 (64.08%) patients had the required parameters for the calculation of the low-density lipoprotein cholesterol (LDL-C) by the Friedewald formula. Ten-year ASCVD risk was not calculated for any of the patients during their clinic visits. Thirty-seven (6.51%) patients had either an LDL-C ≥4.91 mmol/L or an age between 40 and 75 years with diabetes mellitus or ASCVD risk score (when calculated) ≥ 7.5%. Only one of these persons was referred for specialist care of lifestyle modification. Fifty (8.80%) persons had an eGFR <60 mLs/min, but only 11 (1.94%) were referred for nephrology care.

CONCLUSION

The integration of primary preventive cardiovascular practices into routine care for PLHIV is suboptimal. A revision of the recommendations of the Nigerian National Guidelines for HIV may be a useful first step addressing this.

Factors associated with adherence to guideline-recommended cardiovascular disease prevention among HIV clinicians

Integrating cardiovascular disease (CVD) prevention in routine HIV care remains a challenge. This study aimed to identify factors associated with adherence to guideline-recommended CVD preventive practices among HIV clinicians. Clinicians from eight HIV clinics in Atlanta were invited to complete an online survey. The survey was informed by the Consolidated Framework for Implementation Research and assessed the following: clinician CVD risk screening and advice frequency (never to always), individual characteristics (clinician beliefs, self-efficacy, and motivation), inner setting factors (clinic culture, learning climate, leadership engagement, and resources available), and outer setting factors (peer pressure and patient needs). Bivariate correlations examined associations between these factors and guideline adherence. Thirty-eight clinicians completed the survey (82% women, mean age 42 years, 50% infectious disease physicians). For risk screening, clinicians always check patient blood pressure (median score 7.0/7), while they usually ask about smoking or check their blood glucose (median score 6.0/7). For advice provision, clinicians usually recommend quitting smoking, controlling cholesterol or controlling blood pressure (median score 6.0/7), while they often recommend controlling blood glucose, losing weight, or improving diet/physical activity (median score 5.5/7). Clinician beliefs, motivation and self-efficacy were positively correlated with screening and advice practices (r = .55−.84), while inner setting factors negatively correlated with lifestyle-related screening and advice practices (r = −.51 to −.76). Peer pressure was positively correlated with screening and advice practices (r = .57–.89). Clinician psychosocial characteristics and perceived peer pressure positively influence adherence to guideline-recommended CVD preventive practices. These correlates along with leadership engagement could be targeted with proven implementation strategies.

A 10-Years Risk of Cardiovascular Disease Among HIV-Positive Individuals Using BMI-Based Framingham Risk Score in Indonesia

Introduction

Cardiovascular disease (CVD) is the primary cause of death in HIV patients. The number of HIV patients suffering from cardiovascular disease is almost twice as high as that of patients who are not HIV-positive.

Objective

The purpose of this study was to evaluate risk of cardiovascular disease among HIV-positive persons.

Methods

We conducted a cross-sectional study with HIV positive individuals at public health center and non-AIDS govermental organization. We enrolled people diagnosed with HIV, age over 30 years old, and on CVD medications. We collected data of demographic, anthropometric and clinical information, smoking history, and non-fasting cholesterol and blood glucose. Estimation of 10-years CVD risk was calculated using the BMI-based Framingham Risk Score.

Results

Of 150 participants enrolled, 66.7% were male and mean age was 38.09 (SD = 7.99) years. The mean current CD4 counts was 493.3 (SD = 139.8) cells/mm3. Female were younger, had a shorter duration living with HIV and a shorted duration of receiving ART than males. About 8.7% of respondents had a high risk of developing a CVD event in the next 10 years, and higher among females than males. The most common CVD risk factors were smoking, high blood pressure, and hypercholestrolemia.

Conclusion

Our study demonstrates that HIV positive persons who are at risk for developing CVD in the next 10-years. There is an increasing need for educational programs on CVD prevention for the HIV-positive person and to further facilitate the identification of persons at elevated risk in routine practice.

Screening and management of risk factors for cardiovascular disease in HIV-positive patients attending an Australian urban sexual health clinic

Background Few data exist regarding cardiovascular risk among HIV-infected patients attending sexual health clinics (SHC) in Australia.

METHODS

The medical records of 188 patients attending an inner-city SHC between August 2013 and July 2014 were retrospectively reviewed for cardiovascular risk factors and associated screening and management practices.

RESULTS

Cardiovascular risk factors were common among attendees of the SHC, including smoking (38%), hypertension (14%) and dyslipidaemia (11%). Of the 188 patients, 23% reported using potentially cardiotoxic recreational drugs, 25% of dyslipidaemic patients were not on therapy and 10% of patients were hypertensive; none were prescribed treatment. A smoking cessation program was offered to all patients.

CONCLUSION

A high prevalence of risk factors for cardiovascular disease was demonstrated. Modification of risk factors could be improved.

The systematic development of a complex intervention: HealthMap, an online self-management support program for people with HIV

Background

Despite persistent calls for HIV care to adopt a chronic care approach, few HIV treatment services have been able to establish service arrangements that prioritise self-management. To prevent cardiovascular and other chronic disease outcomes, the HealthMap program aims to enhance routine HIV care with opportunities for self-management support. This paper outlines the systematic process that was used to design and develop the HealthMap program, prior to its evaluation in a cluster-randomised trial.

Methods

Program development, planning and evaluation was informed by the PRECEDE-PROCOEDE Model and an Intervention Mapping approach and involved four steps: (1) a multifaceted needs assessment; (2) the identification of intervention priorities; (3) exploration and identification of the antecedents and reinforcing factors required to initiate and sustain desired change of risk behaviours; and finally (4) the development of intervention goals, strategies and methods and integrating them into a comprehensive description of the intervention components.

Results

The logic model incorporated the program’s guiding principles, program elements, hypothesised causal processes, and intended program outcomes. Grounding the development of HealthMap on a clear conceptual base, informed by the research literature and stakeholder’s perspectives, has ensured that the HealthMap program is targeted, relevant, provides transparency, and enables effective program evaluation.

Conclusions

The use of a systematic process for intervention development facilitated the development of an intervention that is patient centred, accessible, and focuses on the key determinants of health-related outcomes for people with HIV in Australia. The techniques used here may offer a useful methodology for those involved in the development and implementation of complex interventions.

Metabolic and Cardiovascular Comorbidities Among Clinically Stable HIV Patients on Long-Term ARV Therapy in Five Ambulatory Clinics in Lima-Callao, Peru

Background:

There is scarcity of data about the prevalence of non-AIDS defining comorbidities among stable HIV-infected patients in Peru.

Objective:

We aimed to describe the most frequent cardiometabolic comorbidities found among ambulatory adults on ARV in Peru.

Methods:

A review of records for patients attending regular visits at 5 clinics in Lima-Callao in January-February 2016 is presented. Patients were adults on ARV for >6 months, with no recent AIDS-defining condition.

Results:

Three hundred and five medical charts were reviewed. Most patients were male (73.1%, n=223) with a mean age of 46.0 years. Mean time from HIV diagnosis was 9.41 yrs. and mean duration of ARV was 7.78 yrs. Most patients were on an NNRTI-based first line regimen (76.4%, n=233), and 12.1% (n=37) were on rescue regimens. Median CD4 count was 614.2 cells/µL and the proportion of patients with viral load <40 c/mL was 90.8% (n=277). Most frequent metabolic diagnoses were dyslipidemia (51.5%, n=157), obesity (11.1%, n=34), and diabetes mellitus (7.2%, n=22). Hypertension was diagnosed in 8.9% (n=27). Other diagnoses of cardiovascular disease were documented in 3.3% (n=10). Pharmacologic treatment was prescribed in 91.3% of patients with diabetes or hypertension, but in only 29.3% of patients with dyslipidemia.

Conclusion:

A high proportion of metabolic comorbidities was found, with dyslipidemia being the most frequent, followed by obesity and diabetes. In contrast, cardiovascular disease was documented less frequently. Medical treatment was started for only a third of dyslipidemia patients. HIV care policies need to consider proper management of chronic comorbidities to optimize long-term outcomes.

Increased homocysteine plasma level is associated with shortened prothrombin time in HIV-infected patients

OBJECTIVE

To find factors associated with increased homocysteine plasma level in HIV-infected patients.

METHODS

Cross-sectional study, carried out as a supplementary task to the standard care of HIV-infected patients. The possible association of increased homocysteine plasma level with blood analyses results was assessed with a multiple linear regression analysis, using the automatic linear modeling available in SPSS version 22.

RESULTS

A total of 145 patients were included. Creatinine was higher than normal in 7 patients (5%), prothrombin time was shortened in 36 patients (25%), and a monoclonal gammopathy was detected in 2 patients (1%). In the regression analysis, an association was found between high homocysteine plasma level and the following variables: low prothrombin time (β coefficient -0.286, confidence interval -1.1854 to -0.754, p < 0.001), high creatinine (coefficient 9.926, confidence interval 6.351-15.246, p < 0.001), low folic acid (coefficient -0.331, confidence interval -0-483 to -0.187, p < 0.001), and low vitamin B12 (coefficient -0.007, confidence interval -0.01 to -0.001, p = 0.005).

CONCLUSION

An association was found between increased homocysteine plasma level and shortened prothrombin time.

HealthMap: a cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV

BACKGROUND

The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV.

METHODS/DESIGN

The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ).

DISCUSSION

The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access.

TRIAL REGISTRATION

Universal Trial Number (UTN) U111111506489; ClinicalTrial.gov Id NCT02178930 submitted 29 June 2014.