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Prakash P, Swami Vetha BS, Chakraborty R, Wenegieme TY, Masenga SK, Muthian G, Balasubramaniam M, Wanjalla CN, Hinton AO, Kirabo A, Williams CR, Aileru A, Dash C. HIV-Associated Hypertension: Risks, Mechanisms, and Knowledge Gaps. Circ Res 2024; 134:e150-e175. [PMID: 38781298 PMCID: PMC11126208 DOI: 10.1161/circresaha.124.323979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
HIV type 1 (HIV-1) is the causative agent of AIDS. Since the start of the epidemic, HIV/AIDS has been responsible for ≈40 million deaths. Additionally, an estimated 39 million people are currently infected with the virus. HIV-1 primarily infects immune cells, such as CD4+ (cluster of differentiation 4+) T lymphocytes (T cells), and as a consequence, the number of CD4+ T cells progressively declines in people living with HIV. Within a span of ≈10 years, HIV-1 infection leads to the systemic failure of the immune system and progression to AIDS. Fortunately, potent antiviral therapy effectively controls HIV-1 infection and prevents AIDS-related deaths. The efficacy of the current antiviral therapy regimens has transformed the outcome of HIV/AIDS from a death sentence to a chronic disease with a prolonged lifespan of people living with HIV. However, antiviral therapy is not curative, is challenged by virus resistance, can be toxic, and, most importantly, requires lifelong adherence. Furthermore, the improved lifespan has resulted in an increased incidence of non-AIDS-related morbidities in people living with HIV including cardiovascular diseases, renal disease, liver disease, bone disease, cancer, and neurological conditions. In this review, we summarize the current state of knowledge of the cardiovascular comorbidities associated with HIV-1 infection, with a particular focus on hypertension. We also discuss the potential mechanisms known to drive HIV-1-associated hypertension and the knowledge gaps in our understanding of this comorbid condition. Finally, we suggest several directions of future research to better understand the factors, pathways, and mechanisms underlying HIV-1-associated hypertension in the post-antiviral therapy era.
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Affiliation(s)
- Prem Prakash
- The Center for AIDS Health Disparities Research
- Department of Microbiology, Immunology, and Physiology
- Department of Biochemistry, Cancer Biology, Pharmacology and Neuroscience Meharry Medical College, Nashville, Tennessee, 37208, USA
| | - Berwin Singh Swami Vetha
- Department of Foundational Sciences and Research, School of Dental Medicine, East Carolina University, 1851 MacGregor Downs Road, MS 701, Greenville, NC 27834
| | - Rajasree Chakraborty
- The Center for AIDS Health Disparities Research
- Department of Microbiology, Immunology, and Physiology
- Department of Biochemistry, Cancer Biology, Pharmacology and Neuroscience Meharry Medical College, Nashville, Tennessee, 37208, USA
| | - Tara-Yesomi Wenegieme
- Department of Neuroscience, Cell Biology and Physiology; Boonshoft School of Medicine and the College of Science and Mathematics; Wright State University, Dayton, OH 45435, USA
| | - Sepiso K. Masenga
- HAND Research Group, School of Medicine and Health Sciences, Mulungushi University, Kabwe, Central Province, 10101, Zambia
- HAND Research Group, School of Medicine and Health Sciences, Mulungushi University, Kabwe, Central Province, 10101, Zambia
| | - Gladson Muthian
- The Center for AIDS Health Disparities Research
- Department of Microbiology, Immunology, and Physiology
- Department of Biochemistry, Cancer Biology, Pharmacology and Neuroscience Meharry Medical College, Nashville, Tennessee, 37208, USA
| | - Muthukumar Balasubramaniam
- The Center for AIDS Health Disparities Research
- Department of Microbiology, Immunology, and Physiology
- Department of Biochemistry, Cancer Biology, Pharmacology and Neuroscience Meharry Medical College, Nashville, Tennessee, 37208, USA
| | | | - Antentor O Hinton
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN 37232, USA
| | - Annet Kirabo
- Division of Clinical Pharmacology, Department of Medicine
- Vanderbilt Center for Immunobiology
- Vanderbilt Institute for Infection, Immunology and Inflammation
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Clintoria R. Williams
- Department of Neuroscience, Cell Biology and Physiology; Boonshoft School of Medicine and the College of Science and Mathematics; Wright State University, Dayton, OH 45435, USA
| | - Azeez Aileru
- Department of Foundational Sciences and Research, School of Dental Medicine, East Carolina University, 1851 MacGregor Downs Road, MS 701, Greenville, NC 27834
| | - Chandravanu Dash
- The Center for AIDS Health Disparities Research
- Department of Microbiology, Immunology, and Physiology
- Department of Biochemistry, Cancer Biology, Pharmacology and Neuroscience Meharry Medical College, Nashville, Tennessee, 37208, USA
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Jones R, Robinson AT, Beach LB, Lindsey ML, Kirabo A, Hinton A, Erlandson KM, Jenkins ND. Exercise to Prevent Accelerated Vascular Aging in People Living With HIV. Circ Res 2024; 134:1607-1635. [PMID: 38781293 PMCID: PMC11126195 DOI: 10.1161/circresaha.124.323975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Given advances in antiretroviral therapy, the mortality rate for HIV infection has dropped considerably over recent decades. However, people living with HIV (PLWH) experience longer life spans coupled with persistent immune activation despite viral suppression and potential toxicity from long-term antiretroviral therapy use. Consequently, PLWH face a cardiovascular disease (CVD) risk more than twice that of the general population, making it the leading cause of death among this group. Here, we briefly review the epidemiology of CVD in PLWH highlighting disparities at the intersections of sex and gender, age, race/ethnicity, and the contributions of social determinants of health and psychosocial stress to increased CVD risk among individuals with marginalized identities. We then overview the pathophysiology of HIV and discuss the primary factors implicated as contributors to CVD risk among PLWH on antiretroviral therapy. Subsequently, we highlight the functional evidence of premature vascular dysfunction as an early pathophysiological determinant of CVD risk among PLWH, discuss several mechanisms underlying premature vascular dysfunction in PLWH, and synthesize current research on the pathophysiological mechanisms underlying accelerated vascular aging in PLWH, focusing on immune activation, chronic inflammation, and oxidative stress. We consider understudied aspects such as HIV-related changes to the gut microbiome and psychosocial stress, which may serve as mechanisms through which exercise can abrogate accelerated vascular aging. Emphasizing the significance of exercise, we review various modalities and their impacts on vascular health, proposing a holistic approach to managing CVD risks in PLWH. The discussion extends to critical future study areas related to vascular aging, CVD, and the efficacy of exercise interventions, with a call for more inclusive research that considers the diversity of the PLWH population.
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Affiliation(s)
- Raymond Jones
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Lauren B. Beach
- Department of Medical Social Sciences, Northwestern, Chicago, IL
- Department of Preventive Medicine, Northwestern, Chicago, IL
| | - Merry L. Lindsey
- School of Graduate Studies, Meharry Medical College, Nashville, TN
- Research Service, Nashville VA Medical Center, Nashville, TN
| | - Annet Kirabo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Center for Immunobiology, Nashville, TN
- Vanderbilt Institute for Infection, Immunology and Inflammation, Nashville, TN
- Vanderbilt Institute for Global Health, Nashville, TN
| | - Antentor Hinton
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | | | - Nathaniel D.M. Jenkins
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA
- Abboud Cardiovascular Research Center, University of Iowa, Iowa City, IA
- Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City, IA
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Nazari I, Feinstein MJ. Evolving mechanisms and presentations of cardiovascular disease in people with HIV: implications for management. Clin Microbiol Rev 2024; 37:e0009822. [PMID: 38299802 PMCID: PMC10938901 DOI: 10.1128/cmr.00098-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
People with HIV (PWH) are at elevated risk for cardiovascular diseases (CVDs), including myocardial infarction, heart failure, and sudden cardiac death, among other CVD manifestations. Chronic immune dysregulation resulting in persistent inflammation is common among PWH, particularly those with sustained viremia and impaired CD4+ T cell recovery. This inflammatory milieu is a major contributor to CVDs among PWH, in concert with common comorbidities (such as dyslipidemia and smoking) and, to a lesser extent, off-target effects of antiretroviral therapy. In this review, we discuss the clinical and mechanistic evidence surrounding heightened CVD risks among PWH, implications for specific CVD manifestations, and practical guidance for management in the setting of evolving data.
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Affiliation(s)
- Ilana Nazari
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew J. Feinstein
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Cardiology in the Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Jia DT, Carcamo PM, Diaz MM. Ongoing Healthcare Disparities in neuroHIV: Addressing Gaps in the Care Continuum. Curr HIV/AIDS Rep 2023; 20:368-378. [PMID: 37999827 DOI: 10.1007/s11904-023-00683-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW We aim to review the neurological complications of HIV and the social, cultural, and economic inequalities that contribute to disparities in neuroHIV care. RECENT FINDINGS Disparities in diagnostics and care of patients with neurological infections and non-infectious conditions associated with HIV in both high-income and low-to-middle-income countries (LMIC) are common. The COVID-19 pandemic has exacerbated these disparities. Factors, such as HIV-related stigma, may deter people from accessing HIV treatment. First-line recommended treatments for neurological infections are not available in many LMICs, leading to inadequate treatment and exposure to agents with more harmful side effect profiles. Access-related factors, such as lack of transportation, lack of health insurance, and inadequate telehealth access, may increase the risk of HIV-related neurological complications. Further research is needed to increase awareness of neurological complications among providers and PWH, and regional guidelines should be considered to better address these complications.
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Affiliation(s)
- Dan Tong Jia
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Paloma M Carcamo
- Laboratory of Epidemiology and Public Health, Yale School of Public Health, New Haven, CT, USA
- Health Innovation Laboratory, Alexander Von Humboldt Tropical Medicine Institute, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Monica M Diaz
- Department of Neurology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
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Mushin AS, Trevillyan JM, Lee SJ, Hearps AC, Hoy JF. Factors associated with the development of coronary artery disease in people with HIV. Sex Health 2023; 20:470-474. [PMID: 37394729 DOI: 10.1071/sh23043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/13/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND People living with HIV (PLHIV) are at increased risk for coronary artery disease (CAD). This study aimed to describe the features associated with CAD in PLHIV. METHODS A case ([n =160] PLHIV with CAD) control ([n =317] PLHIV matched by age and sex without CAD) study was performed at the Alfred Hospital, Melbourne, Australia (January 1996 and December 2018). Data collected included CAD risk factors, duration of HIV infection, nadir and at-event CD4+ T-cell counts, CD4:CD8 ratio, HIV viral load, and antiretroviral therapy exposure. RESULTS Participants were predominantly male (n =465 [97.4%]), with a mean age of 53years. Traditional risk factors associated with CAD in univariate analysis included hypertension (OR 11.4 [95%CI 5.01, 26.33], P <0.001), current cigarette smoking (OR 2.5 [95% CI 1.22, 5.09], P =0.012), and lower high-density lipoprotein cholesterol (OR 0.14 [95%CI 0.05, 0.37], P <0.001). There was no association between duration of HIV infection, nadir or current CD4 cell count. However, current and ever exposure to abacavir (cases: 55 [34.4%]; controls: 79 [24.9%], P =0.023 and cases: 92 [57.5%]; controls: 154 [48.6%], P =0.048, respectively) was associated with CAD. In conditional logistic regression analysis, current abacavir use, current smoking, and hypertension remained significantly associated (aOR=1.87 [CI=1.14, 3.07], aOR=2.31 [1.32, 4.04], and aOR=10.30 [5.25, 20.20] respectively). CONCLUSION Traditional cardiovascular risk factors and exposure to abacavir were associated with CAD in PLHIV. This study highlights that aggressive management of cardiovascular risk factors remains critical for reducing risk in PLHIV.
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Affiliation(s)
- Ari S Mushin
- Department of Infectious Diseases, Monash University, Melbourne, Vic., Australia
| | - Janine M Trevillyan
- Department of Infectious Diseases, Austin Health, Melbourne, Vic., Australia; and Department of Infectious Diseases at the Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Vic., Australia
| | - Sue J Lee
- Department of Infectious Diseases, Monash University, Melbourne, Vic., Australia; and Department of Infectious Diseases, Alfred Hospital, Melbourne, Vic., Australia
| | - Anna C Hearps
- Department of Infectious Diseases, Monash University, Melbourne, Vic., Australia; and Life Sciences Discipline, Burnet Institute, Melbourne, Vic., Australia
| | - Jennifer F Hoy
- Department of Infectious Diseases, Monash University, Melbourne, Vic., Australia; and Department of Infectious Diseases, Alfred Hospital, Melbourne, Vic., Australia
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Pedersen KBH, Knudsen A, Møller S, Siebner HR, Hove JD, Gerstoft J, Benfield T. Changes in weight, body composition and metabolic parameters after switch to dolutegravir/lamivudine compared with continued treatment with dolutegravir/abacavir/lamivudine for virologically suppressed HIV infection (The AVERTAS trial): a randomised, open-label, superiority trial in Copenhagen, Denmark. BMJ Open 2023; 13:e075673. [PMID: 37604629 PMCID: PMC10445393 DOI: 10.1136/bmjopen-2023-075673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/13/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION With longer life expectancy in people living with HIV (PLWH) on antiretroviral therapy, cardiovascular disease (CVD) has become a common cause of mortality among them. Abacavir has been associated with an increased risk of myocardial infarction, but the mechanism is unknown. Additionally, abacavir may be obesogenic which could mediate an additional risk factor of CVD. We aim to investigate if discontinuation of abacavir will have a favourable impact on body weight and cardiac parameters in PLWH. METHODS AND ANALYSIS Randomised, controlled, superiority trial of virologically suppressed PLWH on dolutegravir, abacavir and lamivudine (DTG/ABC/3TC) for ≥6 months. In total, 70 PLWH will be randomised 1:2 to either continue DTG/ABC/3TC or to switch to dolutegravir and lamivudine (DTG/3TC) providing the power of 80% at alpha 5% to detect a mean difference in weight change of 2 kg (Δ) given an SD of 2.7 kg. Follow-up will be 48 weeks. Data will be collected at baseline and week 48. Primary outcome will be change in mean body weight from baseline to week 24 and 48 evaluated in a linear mixed model. Secondary outcomes will be changes in cardiac, inflammatory and metabolic parameters, fat distribution, coagulation, endothelial, platelet function, quality of life and virological control from baseline to week 48. Measurements include CT of thorax and abdomen, external carotid artery ultrasound, liver elastography and dual energy X-ray absorptiometry and blood analysis. Plasma HIV RNA will be measured at baseline, week 4, 24 and 48. Forty participants (20 from each arm) will be included in a substudy involving cardiac MRI at baseline and week 48. Twenty non-HIV-infected controls will be included with a single scan to compare with baseline scan data. ETHICS AND DISSEMINATION Result from this study will lead to a better understanding of the association between antiretroviral therapy and the impact on weight and risk of CVD. Findings will be useful for both clinicians and PLWH in the guidance of a more individualised HIV treatment. Results from the main study and the substudies will be submitted for publication in a peer-reviewed journal(s). The AVERTAS study is approved by the Ethics Committee of the Capital Region, Denmark (H-20011433), Danish Medicines Agency (EudraCT no. 2019-004999-19) and Regional Data Protection Centre (P-2020-207). TRIAL REGISTRATION NUMBER Pre-results registration at ClinicalTrials.gov Identifier: NCT04904406, registered 27 May 2021. PROTOCOL VERSION Protocol version 9.0, 4 April 2023, approved 10-05-2023 by Ethics Committee of the Capital Region, Denmark (H-20011433). Danish Medicines Agency (EudraCT no. 2019-004999-19). Regional Data Protection Centre (P-2020-207) ClinicalTrials.gov.
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Affiliation(s)
- Karen Brorup Heje Pedersen
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Andreas Knudsen
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Hartwig Roman Siebner
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Danish Research Centre for Magnetic Resonance (DRCMR), Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Jens Dahlgaard Hove
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Hvidovre Hospital, Hvidovre, Denmark
| | - Jan Gerstoft
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital- Rigshospitalet, Copenhagen, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Rebeiro PF, Emond B, Rossi C, Bookhart BK, Shah A, Caron‐Lapointe G, Lafeuille M, Donga P. Incidence of cardiometabolic outcomes among people living with HIV-1 initiated on integrase strand transfer inhibitor versus non-integrase strand transfer inhibitor antiretroviral therapies: a retrospective analysis of insurance claims in the United States. J Int AIDS Soc 2023; 26:e26123. [PMID: 37306118 PMCID: PMC10258864 DOI: 10.1002/jia2.26123] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 05/17/2023] [Indexed: 06/13/2023] Open
Abstract
INTRODUCTION Integrase strand transfer inhibitor (INSTI)-containing antiretroviral therapy (ART) has been associated with weight gain, though there is limited information on associations between ART-related weight gain and cardiometabolic outcomes among people living with HIV-1 (PLWH). We, therefore, evaluated risks of incident cardiometabolic outcomes following INSTI versus non-INSTI-based ART initiation in the United States. METHODS We conducted a retrospective study using IBM MarketScan Research Databases (12 August 2012-31 January 2021). Treatment-naïve PLWH initiating ART (index date) on/after 12 August 2013 (approval date of the first second-generation INSTI, dolutegravir) were included and censored at regimen switch/discontinuation, end of insurance eligibility or end of data availability. We used inverse probability of treatment weights constructed with baseline (12 months pre-index) characteristics to account for differences between INSTI- and non-INSTI-initiating cohorts. Doubly robust hazard ratios (HRs) obtained from weighted multivariable Cox regression were used to compare time to incident cardiometabolic outcomes (congestive heart failure [CHF], coronary artery disease, myocardial infarction, stroke/transient ischemic attack, hypertension, type II diabetes, lipid disorders, lipodystrophy and metabolic syndrome) by INSTI-initiation status. RESULTS Weighted INSTI (mean age = 39 years, 23% female, 70% commercially insured, 30% Medicaid insured) and non-INSTI (mean age = 39 years, 24% female, 71% commercially insured, 29% Medicaid insured) cohorts included 7059 and 7017 PLWH, respectively. The most common INSTI-containing regimens were elvitegravir-based (43.4%), dolutegravir-based (33.3%) and bictegravir-based (18.4%); the most common non-INSTI-containing regimens were darunavir-based (31.5%), rilpivirine-based (30.4%) and efavirenz-based (28.3%). Mean±standard deviation follow-up periods were 1.5±1.5 and 1.1±1.2 years in INSTI- and non-INSTI-initiating cohorts, respectively. INSTI initiators were at a clinically and significantly increased risk of experiencing incident CHF (HR = 2.12, 95% confidence interval [CI] = 1.08-4.05; p = 0.036), myocardial infarction (HR = 1.79, 95% CI = 1.03-5.65; p = 0.036) and lipid disorders (HR = 1.26, 95% CI = 1.04-1.58; p = 0.020); there was no evidence of an increased risk for other individual or composite outcomes. CONCLUSIONS Over a short average follow-up period of <2 years, INSTI use among treatment-naïve PLWH was associated with an increased risk of several cardiometabolic outcomes, such as CHF, myocardial infarction and lipid disorders, compared to non-INSTI use. Further research accounting for additional potential confounders and with longer follow-up is warranted to more accurately and precisely quantify the impact of INSTI-containing ART on long-term cardiometabolic outcomes.
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Affiliation(s)
- Peter F. Rebeiro
- Divisions of Infectious Diseases & EpidemiologyDepartment of MedicineDepartment of BiostatisticsVanderbilt UniversityNashvilleTennesseeUSA
| | | | | | | | - Aditi Shah
- Analysis Group, Inc.MontréalQuébecCanada
| | | | | | - Prina Donga
- Janssen Scientific AffairsLLCTitusvilleNew JerseyUSA
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Akinosoglou K, Kolosaka M, Schinas G, Delastic AL, Antonopoulou S, Perperis A, Marangos M, Mouzaki A, Gogos C. Association of Antiretroviral Therapy with Platelet Function and Systemic Inflammatory Response in People Living with HIV: A Cross-Sectional Study. Microorganisms 2023; 11:microorganisms11040958. [PMID: 37110381 PMCID: PMC10144397 DOI: 10.3390/microorganisms11040958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
People living with HIV (PLWHIV) present an increased risk of adverse cardiovascular events. We aimed to assess whether antiretroviral therapy (ART) pharmacologically enhances platelet reactivity and platelet activation intensity, and explore the potential association with underlying inflammatory status. This was a cross-sectional cohort study carried out among PLWHIV on diverse ART regimens. Platelet reactivity and activation intensity were assessed using the bedside point-of-care VerifyNow assay, in P2Y12 reaction units (PRU), measurements of monocyte-platelet complexes, and P-selectin and GPIIb/IIIa expression increase, following activation with ADP, respectively. Levels of major inflammatory markers and whole blood parameters were also evaluated. In total, 71 PLWHIV, 59 on ART and 22 healthy controls, were included in this study. PRU values were significantly elevated in PLWHIV compared to controls [Mean; 257.85 vs. 196.67, p < 0.0001], but no significant differences were noted between ART-naïve or ART-experienced PLWHIV, or between TAF/TDF and ABC based regimens, similar to systemic inflammatory response. However, within-group analysis showed that PRUs were significantly higher in ABC/PI vs ABC/INSTI or TAF/TDF + PI patients, in line with levels of IL-2. PRU values did not correlate strongly with CD4 counts, viral load, or cytokine values. P-selectin and GPIIb/IIIa expression increased following ADP activation and were significantly more prominent in PLWHIV (p < 0.005). Platelet reactivity and platelet activation intensity were shown to be increased in PLWHIV, but they did not appear to be related to ART initiation, similar to the underlying systemic inflammatory response.
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Affiliation(s)
- Karolina Akinosoglou
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
- Medical School, University of Patras, 26504 Patras, Greece
- Division of Infectious Diseases, Department of Internal Medicine, University of Patras, 26504, Patras, Greece
| | - Martha Kolosaka
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
| | - George Schinas
- Medical School, University of Patras, 26504 Patras, Greece
| | - Anne-Lise Delastic
- Laboratory of Immuno-Hematology, Medical School, University of Patras, 26504 Patras, Greece
| | - Stefania Antonopoulou
- Laboratory of Immuno-Hematology, Medical School, University of Patras, 26504 Patras, Greece
| | - Angelos Perperis
- Department of Cardiology, University General Hospital of Patras, 26504 Patras, Greece
| | - Markos Marangos
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
- Medical School, University of Patras, 26504 Patras, Greece
- Division of Infectious Diseases, Department of Internal Medicine, University of Patras, 26504, Patras, Greece
| | - Athanasia Mouzaki
- Medical School, University of Patras, 26504 Patras, Greece
- Laboratory of Immuno-Hematology, Medical School, University of Patras, 26504 Patras, Greece
| | - Charalambos Gogos
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
- Medical School, University of Patras, 26504 Patras, Greece
- Division of Infectious Diseases, Department of Internal Medicine, University of Patras, 26504, Patras, Greece
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Fragkou PC, Moschopoulos CD, Dimopoulou D, Triantafyllidi H, Birmpa D, Benas D, Tsiodras S, Kavatha D, Antoniadou A, Papadopoulos A. Cardiovascular disease and risk assessment in people living with HIV: Current practices and novel perspectives. Hellenic J Cardiol 2023; 71:42-54. [PMID: 36646212 DOI: 10.1016/j.hjc.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/28/2022] [Accepted: 12/31/2022] [Indexed: 01/15/2023] Open
Abstract
Human immunodeficiency virus (HIV) infection represents a major cardiovascular risk factor, and the cumulative cardiovascular disease (CVD) burden among aging people living with HIV (PLWH) constitutes a leading cause of morbidity and mortality. To date, CVD risk assessment in PLWH remains challenging. Therefore, it is necessary to evaluate and stratify the cardiovascular risk in PLWH with appropriate screening and risk assessment tools and protocols to correctly identify which patients are at a higher risk for CVD and will benefit most from prevention measures and timely management. This review aims to accumulate the current evidence on the association between HIV infection and CVD, as well as the risk factors contributing to CVD in PLWH. Furthermore, considering the need for cardiovascular risk assessment in daily clinical practice, the purpose of this review is also to report the current practices and novel perspectives in cardiovascular risk assessment of PLWH and provide further insights into the development and implementation of appropriate CVD risk stratification and treatment strategies, particularly in countries with high HIV burden and limited resources.
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Affiliation(s)
- Paraskevi C Fragkou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | - Charalampos D Moschopoulos
- Fourth Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitra Dimopoulou
- Second Department of Pediatrics, Children's Hospital "Panagiotis and Aglaia Kyriakou", National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Helen Triantafyllidi
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dionysia Birmpa
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Benas
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Sotirios Tsiodras
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitra Kavatha
- Fourth Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Anastasia Antoniadou
- Fourth Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Antonios Papadopoulos
- Fourth Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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10
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Tsuro U, Oladimeji KE, Pulido-Estrada GA, Apalata TR. Risk Factors Attributable to Hypertension among HIV-Infected Patients on Antiretroviral Therapy in Selected Rural Districts of the Eastern Cape Province, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11196. [PMID: 36141463 PMCID: PMC9517599 DOI: 10.3390/ijerph191811196] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Antiretroviral therapy has improved HIV patients' quality of life and life expectancy. However, complications have emerged in the form of hypertension. In the rural Eastern Cape, there is minimal information about HIV-infected people. The current study intended to evaluate the factors associated with hypertension in HIV-infected individuals receiving antiretroviral therapy in rural areas of South Africa's Eastern Cape. METHODS For this cohort study, HIV-positive people taking antiretroviral therapy aged 15 and up were recruited at random from several rural locations in the Eastern Cape. Using Cox univariate and multivariate analyses, the key predictors of hypertension were found. RESULTS Of the total participants (n = 361), 53% of individuals had hypertension. In the Cox multivariate model, patients that had hypertension heredity, BMI ≥ 25 kg/m2, eGFR < 60 mL/min/1.73 m2, advanced and severe CD4 counts, 1TFE and 1T3E regimens, and the male gender were found to be at greater risk of hypertension. CONCLUSIONS The findings of this study indicate that hypertension is a prevalent concern among HIV patients receiving antiretroviral therapy. HIV patients should have their blood pressure checked regularly, and they should be screened for high blood pressure and given treatment for it.
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Affiliation(s)
- Urgent Tsuro
- Department of Public Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa
| | - Kelechi E. Oladimeji
- Department of Public Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa
- Department of Laboratory Medicine and Pathology, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa
- College of Graduate Studies, University of South Africa, Pretoria 0001, South Africa
| | | | - Teke R. Apalata
- Department of Laboratory Medicine and Pathology, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa
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11
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Martinez CA, Rikhi R, Pester MS, Parker M, Gonzalez A, Larson M, Chavez J, Mendez A, Raines JK, Kolber MA, Schulman IH, Alcaide ML, Hurwitz BE. Abacavir antiretroviral therapy and indices of subclinical vascular disease in persons with HIV. PLoS One 2022; 17:e0264445. [PMID: 35271614 PMCID: PMC8912137 DOI: 10.1371/journal.pone.0264445] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 02/10/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Indices of cardiovascular disease (CVD) risk, vascular endothelial dilation, arterial stiffness and endothelial repair were examined in persons with HIV (PWH) on an antiretroviral therapy (ART) that included abacavir (ABC+) in comparison with PWH on ART without abacavir (ABC-), and with HIV seronegative (HIV-) individuals. Approach The 115 participants (63% men), aged 30–50 years, did not have CVD, metabolic, endocrine, or chronic renal conditions. PWH were on stable ART for six-months or more. Vascular assessments included flow-mediated dilation (FMD), aortic, radial and femoral arterial stiffness (cAIx, crPWV, cfPWV), and thigh and calf arterial compliance (Vmax50). Endothelial repair was indexed by endothelial progenitor cell colony forming units (EPC-CFU). Traditional CVD risk measures included blood pressure, central adiposity, lipids, insulin resistance (HOMA-IR), CRP and ASCVD score. Analyses controlled for demographics (age, sex, education), medications (antihypertensive, statin/fibrate, antipsychotic), and substance abuse (ASSIST). Results No group differences were observed in central adiposity, HOMA-IR, CRP, or ASCVD risk score. However, the ABC- group displayed greater dyslipidemia. The ABC+ group displayed no difference on FMD, cAIx, cfPWV or calf Vmax50 compared with other groups. When CD4 count and viral load were controlled, no additional differences between the ABC+ and ABC- groups emerged. Analyses of crPWV and thigh Vmax50 suggested supported by a trend toward lower EPC-CFU in the HIV+ groups than the HIV- group. Conclusions Findings indicate that ABC treatment of 30–50 year-old PWH on stable ART is not likely to contribute in a robust way to higher CVD risk.
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Affiliation(s)
- Claudia A. Martinez
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
- * E-mail:
| | - Rishi Rikhi
- Division of Cardiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Mollie S. Pester
- Behavioral Medicine Research Center, University of Miami, Miami, Florida, United States of America
- Department of Psychology, University of Miami, Coral Gables, Florida, United States of America
| | - Meela Parker
- Behavioral Medicine Research Center, University of Miami, Miami, Florida, United States of America
| | - Alex Gonzalez
- Behavioral Medicine Research Center, University of Miami, Miami, Florida, United States of America
| | - Michaela Larson
- Department of Public Health Science, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Jennifer Chavez
- Department of Public Health Science, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Armando Mendez
- Division of Endocrinology, Diabetes and Metabolism, Miller School of Medicine, University of Miami, Miami, Florida, United States of America
| | - Jeffrey K. Raines
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Michael A. Kolber
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Ivonne H. Schulman
- Katz Family Division of Nephrology & Hypertension, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Maria L. Alcaide
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Barry E. Hurwitz
- Behavioral Medicine Research Center, University of Miami, Miami, Florida, United States of America
- Department of Psychology, University of Miami, Coral Gables, Florida, United States of America
- Division of Endocrinology, Diabetes and Metabolism, Miller School of Medicine, University of Miami, Miami, Florida, United States of America
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12
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Dorjee K, Desai M, Choden T, Baxi SM, Hubbard AE, Reingold AL. Acute myocardial infarction associated with abacavir and tenofovir based antiretroviral drug combinations in the United States. AIDS Res Ther 2021; 18:57. [PMID: 34488812 PMCID: PMC8419948 DOI: 10.1186/s12981-021-00383-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Although individual antiretroviral drugs have been shown to be associated with elevated cardiovascular disease (CVD) risk, data are limited on the role of antiretroviral drug combinations. Therefore, we sought to investigate CVD risk associated with antiretroviral drug combinations. METHODS Using an administrative health-plan dataset, risk of acute myocardial infarction (AMI) associated with current exposure to antiretroviral drug combinations was assessed among persons living with HIV receiving antiretroviral therapy (ART) across the U.S. from October 2009 through December 2014. To account for confounding-by-indication and for factors simultaneously acting as causal mediators and confounders, we applied inverse probability of treatment weighted marginal structural models to longitudinal data of patients. RESULTS Over 114,417 person-years (n = 73,071 persons) of ART exposure, 602 cases of AMI occurred at an event rate of 5.26 (95% CI: 4.86, 5.70)/1000 person-years. Of the 14 antiretroviral drug combinations studied, persons taking abacavir-lamivudine-darunavir had the highest incidence rate (IR: 11/1000; 95% CI: 7.4-16.0) of AMI. Risk (HR; 95% CI) of AMI was elevated for current exposure to abacavir-lamivudine-darunavir (1.91; 1.27-2.88), abacavir-lamivudine-atazanavir (1.58; 1.08-2.31), and tenofovir-emtricitabine-raltegravir (1.35; 1.07-1.71). Tenofovir-emtricitabine-efavirenz was associated with reduced risk (0.65; 0.54-0.78). Abacavir-lamivudine-darunavir was associated with increased risk of AMI beyond that expected of abacavir alone, likely attributable to darunavir co-administration. We did not find an elevated risk of AMI when abacavir-lamivudine was combined with efavirenz or raltegravir. CONCLUSION The antiretroviral drug combinations abacavir-lamivudine-darunavir, abacavir-lamivudine-atazanavir and tenofovir-emtricitabine-raltegravir were found to be associated with elevated risk of AMI, while tenofovir-emtricitabine-efavirenz was associated with a lower risk. The AMI risk associated with abacavir-lamivudine-darunavir was greater than what was previously described for abacavir, which could suggest an added risk from darunavir. The results should be confirmed in additional studies.
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13
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Sico JJ, Kundu S, So-Armah K, Gupta SK, Chang CCH, Butt AA, Gibert CL, Marconi VC, Crystal S, Tindle HA, Freiberg MS, Stewart JC. Depression as a Risk Factor for Incident Ischemic Stroke Among HIV-Positive Veterans in the Veterans Aging Cohort Study. J Am Heart Assoc 2021; 10:e017637. [PMID: 34169726 PMCID: PMC8403311 DOI: 10.1161/jaha.119.017637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background HIV infection and depression are each associated with increased ischemic stroke risk. Whether depression is a risk factor for stroke within the HIV population is unknown. Methods and Results We analyzed data on 106 333 (33 528 HIV‐positive; 72 805 HIV‐negative) people who were free of baseline cardiovascular disease from an observational cohort of HIV‐positive people and matched uninfected veterans in care from April 1, 2003 through December 31, 2014. International Classification of Diseases, Ninth Revision (ICD‐9) codes from medical records were used to determine baseline depression and incident stroke. Depression occurred in 19.5% of HIV‐positive people. After a median of 9.2 years of follow‐up, stroke rates were highest among people with both HIV and depression and lowest among those with neither condition. In Cox proportional hazard models, depression was associated with an increased risk of stroke for HIV‐positive people after adjusting for sociodemographic characteristics and cerebrovascular risk factors (hazard ratio [HR], 1.18; 95% CI: 1.03–1.34; 0.014). The depression‐stroke relationship was attenuated by alcohol use disorders, cocaine use, and baseline antidepressant use, and unaffected by combined antiretroviral therapy use or individual antiretroviral agents. A numerically higher HR of depression on stroke was found among those younger than 60 years. Conclusions Depression is associated with an increased risk of stroke among HIV‐positive people after adjusting for sociodemographic characteristics, traditional cerebrovascular risk factors, and HIV‐specific factors. Alcohol use disorders, cocaine use, and baseline antidepressant use accounted for some of the observed stroke risk. Depression may be a novel, independent risk factor for ischemic stroke in HIV, particularly among younger people.
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Affiliation(s)
- Jason J Sico
- Neurology Service VA Connecticut Healthcare System West Haven CT.,Department of Neurology Yale School of Medicine New Haven CT.,Center for NeuroEpidemiological and Clinical Neurological Research Yale School of Medicine New Haven CT.,Department of Internal Medicine Yale School of Medicine New Haven CT.,Clinical Epidemiology Research Center (CERC) VA Connecticut Healthcare System West Haven CT.,Pain Research, Informatics, and Multi-morbidities, and Education (PRIME) Center VA Connecticut Healthcare System West Haven CT.,Vanderbilt Center for Clinical Cardiovascular Outcomes Research and Trials Evaluation (V-CREATE) Vanderbilt University School of Medicine Nashville TN
| | - Suman Kundu
- Vanderbilt Center for Clinical Cardiovascular Outcomes Research and Trials Evaluation (V-CREATE) Vanderbilt University School of Medicine Nashville TN.,Tennessee Valley Geriatrics Research Education and Clinical Centers (GRECC) VA Tennessee Valley Healthcare System Nashville TN
| | | | - Samir K Gupta
- Department of Medicine Indiana University School of Medicine Indianapolis IN
| | | | - Adeel A Butt
- VA Pittsburgh Healthcare System Pittsburgh PA.,Weill Cornell Medical College New York NY.,Weill Cornell Medical College Doha Qatar.,Hamad Medical Corporation Doha Qatar
| | - Cynthia L Gibert
- Washington DC Veterans Affairs Medical Center and George Washington University School of Medicine and Health Sciences Washington DC
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health Emory Center for AIDS Research, and the Atlanta VA Medical Center Atlanta GA
| | - Stephen Crystal
- Center for Health Services Research Institute for Health Rutgers University New Brunswick NJ
| | - Hilary A Tindle
- Tennessee Valley Geriatrics Research Education and Clinical Centers (GRECC) VA Tennessee Valley Healthcare System Nashville TN.,Vanderbilt University Medical Center Nashville TN
| | - Matthew S Freiberg
- Vanderbilt Center for Clinical Cardiovascular Outcomes Research and Trials Evaluation (V-CREATE) Vanderbilt University School of Medicine Nashville TN.,Tennessee Valley Geriatrics Research Education and Clinical Centers (GRECC) VA Tennessee Valley Healthcare System Nashville TN
| | - Jesse C Stewart
- Department of Psychology Indianapolis University-Purdue University Indianapolis (IUPUI) Indianapolis IN
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14
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Shamu T, Chimbetete C, Egger M, Mudzviti T. Treatment outcomes in HIV infected patients older than 50 years attending an HIV clinic in Harare, Zimbabwe: A cohort study. PLoS One 2021; 16:e0253000. [PMID: 34106989 PMCID: PMC8189507 DOI: 10.1371/journal.pone.0253000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 05/26/2021] [Indexed: 11/27/2022] Open
Abstract
There is a growing number of older people living with HIV (OPLHIV). While a significant proportion of this population are adults growing into old age with HIV, there are also new infections among OPLHIV. There is a lack of data describing the outcomes of OPLHIV who commenced antiretroviral therapy (ART) after the age of 50 years in sub-Saharan Africa. We conducted a cohort study of patients who enrolled in care at Newlands Clinic in Harare, Zimbabwe, at ages ≥50 years between February 2004 and March 2020. We examined demographic characteristics, attrition, viral suppression, immunological and clinical outcomes. Specifically, we described prevalent and incident HIV-related communicable and non-communicable comorbidities. We calculated frequencies, medians, interquartile ranges (IQR), and proportions; and used Cox proportional hazards models to identify risk factors associated with death. We included 420 (57% female) who commenced ART and were followed up for a median of 5.6 years (IQR 2.4–9.9). Most of the men were married (n = 152/179, 85%) whereas women were mostly widowed (n = 125/241, 51.9%). Forty per cent (n = 167) had WHO stage 3 or 4 conditions at ART baseline. Hypertension prevalence was 15% (n = 61) at baseline, and a further 27% (n = 112) had incident hypertension during follow-up. During follow-up, 300 (71%) were retained in care, 88 (21%) died, 17 (4%) were lost to follow-up, and 15 (4%) were transferred out. Of those in care, 283 (94%) had viral loads <50 copies/ml, and 10 had viral loads >1000 copies/ml. Seven patients (1.7%) were switched to second line ART during follow-up and none were switched to third-line. Higher baseline CD4 T-cell counts were protective against mortality (p = 0.001) while male sex (aHR: 2.29, 95%CI: 1.21–4.33), being unmarried (aHR: 2.06, 95%CI: 1.13–3.78), and being unemployed (aHR: 2.01, 95%CI: 1.2–3.37) were independent independent risk factors of mortality. There was high retention in care and virologic suppression in this cohort of OPLHIV. Hypertension was a common comorbidity. Being unmarried or unemployed were significant predictors of mortality highlighting the importance of sociologic factors among OPLHIV, while better immune competence at ART commencement was protective against mortality.
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Affiliation(s)
- Tinei Shamu
- Newlands Clinic, Newlands, Harare, Zimbabwe
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School of Health Sciences, University of Bern, Bern, Switzerland
- * E-mail:
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tinashe Mudzviti
- Newlands Clinic, Newlands, Harare, Zimbabwe
- School of Pharmacy, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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15
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Crane HM, Nance RM, Avoundjian T, Harding BN, Whitney BM, Chow FC, Becker KJ, Marra CM, Zunt JR, Ho EL, Kalani R, Huffer A, Burkholder GA, Willig AL, Moore RD, Mathews WC, Eron JJ, Napravnik S, Lober WB, Barnes GS, McReynolds J, Feinstein MJ, Heckbert SR, Saag MS, Kitahata MM, Delaney JA, Tirschwell DL. Types of Stroke Among People Living With HIV in the United States. J Acquir Immune Defic Syndr 2021; 86:568-578. [PMID: 33661824 PMCID: PMC9680532 DOI: 10.1097/qai.0000000000002598] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Most studies of stroke in people living with HIV (PLWH) do not use verified stroke diagnoses, are small, and/or do not differentiate stroke types and subtypes. SETTING CNICS, a U.S. multisite clinical cohort of PLWH in care. METHODS We implemented a centralized adjudication stroke protocol to identify stroke type, subtype, and precipitating conditions identified as direct causes including infection and illicit drug use in a large diverse HIV cohort. RESULTS Among 26,514 PLWH, there were 401 strokes, 75% of which were ischemic. Precipitating factors such as sepsis or same-day cocaine use were identified in 40% of ischemic strokes. Those with precipitating factors were younger, had more severe HIV disease, and fewer traditional stroke risk factors such as diabetes and hypertension. Ischemic stroke subtypes included cardioembolic (20%), large vessel atherosclerosis (13%), and small vessel (24%) ischemic strokes. Individuals with small vessel strokes were older, were more likely to have a higher current CD4 cell count than those with cardioembolic strokes and had the highest mean blood pressure of the ischemic stroke subtypes. CONCLUSION Ischemic stroke, particularly small vessel and cardioembolic subtypes, were the most common strokes among PLWH. Traditional and HIV-related risk factors differed by stroke type/subtype. Precipitating factors including infections and drug use were common. These results suggest that there may be different biological phenomena occurring among PLWH and that understanding HIV-related and traditional risk factors and in particular precipitating factors for each type/subtype may be key to understanding, and therefore preventing, strokes among PLWH.
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Affiliation(s)
| | | | | | | | | | | | | | - Christina M. Marra
- Neurology, University of Washington, Seattle, USA
- Medicine, University of Washington, Seattle, USA
| | - Joseph R. Zunt
- Neurology, University of Washington, Seattle, USA
- Medicine, University of Washington, Seattle, USA
- Epidemiology, University of Washington, Seattle, USA
| | - Emily L. Ho
- Neurology, University of Washington, Seattle, USA
- Swedish Neuroscience Institute, Seattle, USA
| | | | | | | | | | | | | | | | | | - William B. Lober
- Clinical Informatics Research Group, University of Washington, Seattle, USA
| | - Greg S. Barnes
- Clinical Informatics Research Group, University of Washington, Seattle, USA
| | - Justin McReynolds
- Clinical Informatics Research Group, University of Washington, Seattle, USA
| | | | | | | | | | - Joseph A.C. Delaney
- Epidemiology, University of Washington, Seattle, USA
- University of Manitoba, Manitoba, Canada
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16
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Influence of Human Immunodeficiency Virus Infection on the Management and Outcomes of Acute Myocardial Infarction With Cardiogenic Shock. J Acquir Immune Defic Syndr 2021; 85:331-339. [PMID: 32740372 DOI: 10.1097/qai.0000000000002442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There are limited data on the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in patients with HIV infection and AIDS. SETTING Twenty percent sample of all US hospitals. METHODS A retrospective cohort of AMI-CS during 2000-2017 from the National Inpatient Sample was evaluated for concomitant HIV and AIDS. Outcomes of interest included in-hospital mortality and use of cardiac procedures. A subgroup analysis was performed for those with and without AIDS within the HIV cohort. RESULTS A total 557,974 AMI-CS admissions were included, with HIV and AIDS in 1321 (0.2%) and 985 (0.2%), respectively. The HIV cohort was younger (54.1 vs. 69.0 years), more often men, of non-White race, uninsured, from a lower socioeconomic status, and with higher comorbidity (all P < 0.001). The HIV cohort had comparable multiorgan failure (37.8% vs. 39.0%) and cardiac arrest (28.7% vs. 27.4%) (P > 0.05). The cohorts with and without HIV had comparable rates of coronary angiography (70.2% vs. 69.0%; P = 0.37) but less frequent early coronary angiography (hospital day zero) (39.1% vs. 42.5%; P < 0.001). The cohort with HIV had higher unadjusted but comparable adjusted in-hospital mortality compared with those without [26.9% vs. 37.4%; adjusted odds ratio 1.04 (95% confidence interval: 0.90 to 1.21); P = 0.61]. In the HIV cohort, AIDS was associated with higher in-hospital mortality [28.8% vs. 21.1%; adjusted odds ratio 4.12 (95% confidence interval: 1.89 to 9.00); P < 0.001]. CONCLUSIONS The cohort with HIV had comparable rates of cardiac procedures and in-hospital mortality; however, those with AIDS had higher in-hospital mortality.
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17
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Relationship between Endothelial Function, Antiretroviral Treatment and Cardiovascular Risk Factors in HIV Patients of African Descent in South Africa: A Cross-Sectional Study. J Clin Med 2021; 10:jcm10030392. [PMID: 33498530 PMCID: PMC7864186 DOI: 10.3390/jcm10030392] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/28/2020] [Accepted: 12/08/2020] [Indexed: 02/08/2023] Open
Abstract
Limited information on the effect of antiretroviral treatment (ART) on vascular function in South Africans of African descent living with human immunodeficiency virus (HIV) is available. The relationship between ART, vascular function and cardiovascular risk factors in South Africans of African ancestry with HIV was therefore studied. This cross-sectional study recruited 146 HIV-positive individuals on ART (HIV+ART+), 163 HIV-positive individuals not on ART (HIV+ART−) and 171 individuals without HIV (HIV−) in Mthatha, Eastern Cape Province of South Africa. Flow-mediated dilation (FMD) test was performed to assess endothelial function. Anthropometry and blood pressure parameters were measured. Lipid profile, glycaemic indices, serum creatinine as well as CD4 count and viral load were assayed in blood. Urinary albumin to creatinine ratio (ACR) was determined as a marker of cardiovascular risk. Obesity and albuminuria were positively associated with HIV, and HIV+ART+ participants had significantly higher HDL cholesterol. Dyslipidaemia markers were significantly higher in hypertensive HIV+ART+ participants compared with the controls (HIV+ART− and HIV− participants). FMD was not different between HIV+ART+ participants and the controls. Moreover, HIV+ART+ participants with higher FMD showed lower total cholesterol and LDL cholesterol comparable to that of HIV− and HIV+ART− participants. A positive relationship between FMD and CD4 count was observed in HIV+ART+ participants. In conclusion, antiretroviral treatment was associated with cardiovascular risk factors, particularly dyslipidaemia, in hypertensive South Africans of African ancestry with HIV. Although, ART was not associated with endothelial dysfunction, flow-mediated dilatation was positively associated with CD4 count in HIV-positive participants on ART.
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18
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Meng Z, Hernandez R, Liu J, Gwag T, Lu W, Hsiai TK, Kaul M, Zhou T, Zhou C. HIV Protein Tat Induces Macrophage Dysfunction and Atherosclerosis Development in Low-Density Lipoprotein Receptor-Deficient Mice. Cardiovasc Drugs Ther 2021; 36:201-215. [PMID: 33459922 DOI: 10.1007/s10557-021-07141-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE HIV infection is consistently associated with an increased risk of atherosclerotic cardiovascular disease, but the underlying mechanisms remain elusive. HIV protein Tat, a transcriptional activator of HIV, has been shown to activate NF-κB signaling and promote inflammation in vitro. However, the atherogenic effects of HIV Tat have not been investigated in vivo. Macrophages are one of the major cell types involved in the initiation and progression of atherosclerosis. We and others have previously revealed the important role of IκB kinase β (IKKβ), a central inflammatory coordinator through activating NF-κB, in the regulation of macrophage functions and atherogenesis. This study investigated the impact of HIV Tat exposure on macrophage functions and atherogenesis. METHODS To investigate the effects of Tat on macrophage IKKβ activation and atherosclerosis development in vivo, myeloid-specific IKKβ-deficient LDLR-deficient (IKKβΔMyeLDLR-/-) mice and their control littermates (IKKβF/FLDLR-/-) were exposed to recombinant HIV protein Tat. RESULTS Exposure to Tat significantly increased atherosclerotic lesion size and plaque vulnerability in IKKβF/FLDLR-/- but not IKKβΔMyeLDLR-/- mice. Deficiency of myeloid IKKβ attenuated Tat-elicited macrophage inflammatory responses and atherosclerotic lesional inflammation in IKKβΔMyeLDLR-/- mice. Further, RNAseq analysis demonstrated that HIV protein Tat affects the expression of many atherosclerosis-related genes in vitro in an IKKβ-dependent manner. CONCLUSIONS Our findings reveal atherogenic effects of HIV protein Tat in vivo and demonstrate a pivotal role of myeloid IKKβ in Tat-driven atherogenesis.
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Affiliation(s)
- Zhaojie Meng
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA, USA
| | - Rebecca Hernandez
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA, USA
| | - Jingwei Liu
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA, USA
| | - Taesik Gwag
- Department of Pharmacology and Nutritional Sciences, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Weiwei Lu
- Department of Pharmacology and Nutritional Sciences, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Tzung K Hsiai
- Departments of Medicine and Bioengineering, David Geffen School of Medicine, Henry Samueli School of Engineering and Applied Science, University of California, Los Angeles, CA, USA
| | - Marcus Kaul
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA, USA
| | - Tong Zhou
- Department of Physiology and Cell Biology, Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Changcheng Zhou
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA, USA.
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19
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Pushpakom S, Kolamunnage-Dona R, Taylor C, Foster T, Spowart C, García-Fiñana M, Kemp GJ, Jaki T, Khoo S, Williamson P, Pirmohamed M. TAILoR (TelmisArtan and InsuLin Resistance in Human Immunodeficiency Virus [HIV]): An Adaptive-design, Dose-ranging Phase IIb Randomized Trial of Telmisartan for the Reduction of Insulin Resistance in HIV-positive Individuals on Combination Antiretroviral Therapy. Clin Infect Dis 2021; 70:2062-2072. [PMID: 31425580 PMCID: PMC7201422 DOI: 10.1093/cid/ciz589] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/02/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Combination antiretroviral therapy results in metabolic abnormalities which increase cardiovascular disease risk. We evaluated whether telmisartan reduces insulin resistance in human immunodeficiency virus (HIV)-positive individuals on antiretrovirals. METHODS We conducted a multicenter, randomized, open-label, dose-ranging controlled trial of telmisartan. Participants with HIV infection receiving combination antiretroviral therapy were randomized equally to either no intervention (control) or 20, 40, or 80 mg telmisartan once daily. The adaptive design allowed testing of all dose(s) of telmisartan in stage I, with the promising dose(s) being taken into stage II. The primary outcome measure was reduction in homeostasis model assessment of insulin resistance (HOMA-IR) at 24 weeks. RESULTS A total of 377 patients were recruited. In stage I, 48, 49, 47, and 45 patients were randomized to control and 20, 40, and 80 mg telmisartan, respectively (total n = 189). At the interim analysis, 80 mg telmisartan was taken forward into stage II. At the end of stage II (n = 105, control; 106, 80-mg arm), there were no differences in HOMA-IR (estimated effect, 0.007; SE, 0.106) at 24 weeks between the telmisartan (80 mg) and nonintervention arms. Longitudinal analysis over 48 weeks showed no change in HOMA-IR, lipid or adipokine levels. There were significant (P ≤ .05), but marginal, improvements in revised Quantitative Insulin Sensitivity Check Index (QUICKI) (0.004) and plasma hs-CRP (-0.222 mg/L) and reduction in liver fat content (1.714 mean reduction; P = .005). CONCLUSIONS No significant effect of telmisartan was demonstrated on the primary outcome (HOMA-IR), but there were marginal improvements with some secondary outcome measures. Further studies in this population are warranted to identify novel strategies for preventing cardiovascular morbidity and mortality. CLINICAL TRIAL REGISTRATION ISRCTN registry (51069819).
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Affiliation(s)
- Sudeep Pushpakom
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | | | - Claire Taylor
- Clinical Trials Research Centre, University of Liverpool, United Kingdom
| | - Terry Foster
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Cath Spowart
- Clinical Trials Research Centre, University of Liverpool, United Kingdom
| | | | - Graham J Kemp
- Liverpool Magnetic Resonance Imaging Centre, University of Liverpool, United Kingdom
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, United Kingdom
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Paula Williamson
- Department of Biostatistics, University of Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
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Kovari H, Calmy A, Doco-Lecompte T, Nkoulou R, Marzel A, Weber R, Kaufmann PA, Buechel RR, Ledergerber B, Tarr PE. Antiretroviral Drugs Associated With Subclinical Coronary Artery Disease in the Swiss Human Immunodeficiency Virus Cohort Study. Clin Infect Dis 2021; 70:884-889. [PMID: 30958888 DOI: 10.1093/cid/ciz283] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/04/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Coronary artery disease (CAD) events have been associated with certain antiretroviral therapy (ART) agents. In contrast, the influence of ART on subclinical atherosclerosis is not clear. The study objective was to assess the association between individual ART agents and the prevalence and extent of subclinical CAD. METHODS Coronary artery calcium (CAC) scoring and coronary computed tomography angiography (CCTA) were performed in ≥45-year-old Swiss Human Immunodeficiency Virus Cohort Study participants. The following subclinical CAD endpoints were analyzed separately: CAC score >0, any plaque, calcified plaque, noncalcified/mixed plaque, segment involvement score (SIS), and segment severity score (SSS). Logistic regression models calculated by inverse probability of treatment weights (IPTW) were used to explore associations between subclinical CAD and cumulative exposure to the 10 most frequently used drugs. RESULTS There were 403 patients who underwent CCTA. A CAC score >0 was recorded in 188 (47%), any plaque in 214 (53%), calcified plaque in 151 (38%), and noncalcified/mixed plaque in 150 (37%) participants. A CAC score >0 was negatively associated with efavirenz (IPTW adjusted odds ratio per 5 years 0.73, 95% confidence interval [CI] 0.56-0.96), tenofovir disoproxil fumarate (0.68, 95% CI 0.49-0.95), and lopinavir (0.64, 95% CI 0.43-0.96). Any plaque was negatively associated with tenofovir disoproxil fumarate (0.71, 95% CI 0.51-0.99). Calcified plaque was negatively associated with efavirenz (0.7, 95% CI 0.57-0.97). Noncalcified/mixed plaque was positively associated with abacavir (1.46, 95% CI 1.08-1.98) and negatively associated with emtricitabine (0.67, 95% CI 0.46-0.99). For SSS and SIS, we found no association with any drug. CONCLUSIONS An increased risk of noncalcified/mixed plaque was only found in patients exposed to abacavir. Emtricitabine was negatively associated with noncalcified/mixed plaque, while tenofovir disoproxil fumarate and efavirenz were negatively associated with any plaque and calcified plaque, respectively.
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Affiliation(s)
- Helen Kovari
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, University of Zurich, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, University of Geneva, Switzerland
| | | | - René Nkoulou
- Division of Cardiology, University Hospital Geneva, University of Geneva, Switzerland
| | - Alex Marzel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, University of Zurich, Switzerland
| | - Rainer Weber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, University of Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, University of Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, University of Zurich, Switzerland
| | - Bruno Ledergerber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital, University of Zurich, Switzerland
| | - Philip E Tarr
- Department of Medicine and Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital Baselland, University of Basel, Bruderholz, Switzerland
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21
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Haile ZT, Sarfo B, Bonney EY, Mensah EA, Deletsu S. Association between Antiretroviral Treatment and Markers of Systemic Inflammation among HIV Patients in Ghana. Curr HIV Res 2020; 18:466-474. [PMID: 32807057 DOI: 10.2174/1570162x18666200817111152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/27/2020] [Accepted: 07/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Studies from high-income countries have reported that even after receiving antiretroviral treatment (ART), HIV-infected adults may not achieve normal levels of certain inflammatory markers that are known to be associated with the onset and development of non-communicable diseases. OBJECTIVE The aim of this study is to examine the relationship between ART and markers of systemic inflammation in HIV/AIDS patients at an urban antiretroviral clinic in Ghana. METHODS We examined serum levels of high sensitivity CRP (hsCRP), interleukin-6 (IL-6), interleukin- 18(IL-18), and tumor necrosis factor-α (sTNFR1 and sTNFR2) from 40 HIV infected patients. Kruskal-Wallis Test was used to examine the differences in markers of systemic inflammation according to the types of ART medication taken. We then utilized generalized additive models (GAM) with non-linear function to examine the association between ART and markers of systemic inflammation after adjusting for potential confounders. RESULTS Overall, 30 (75.0%) of the participants received ART and 35 (85%) were female. Kruskal- Wallis Test revealed no significant differences in the markers of systemic inflammation among the three categories of ART (none, AZT, 3TC, EFV/NVP, and TDF, 3TC/FTC, EFV/NVP). In the multivariable- adjusted GAM model, we found a significant but non-linear association between time since diagnosis and CRP levels (p=0.006). CONCLUSION Although the relatively small sample size limits the scope of the study's findings, these results suggest that individuals on ART need to be screened periodically for the development of chronic conditions. This line of investigation has the potential to influence treatment and clinical guidelines that will improve the quality of care for HIV-infected patients.
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Affiliation(s)
- Zelalem T Haile
- Department of Social Medicine, Ohio University Heritage College of Osteopathic Medicine, Dublin OH-43016, United States
| | - Bismark Sarfo
- Department of Epidemiology and Disease Control, University of Ghana School of Public Health, Legon, Ghana
| | - Evelyn Y Bonney
- Department of Virology, University of Ghana Noguchi Memorial Institute for Medical Research, Legon, Ghana
| | - Eric A Mensah
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Ghana
| | - Selase Deletsu
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Ghana
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Boettiger DC, Escuder MM, Law MG, Veloso V, Souza RA, Ikeda MLR, deAlencastro PR, Tupinambás U, Brites C, Grinsztejn B, Ggomes JO, Ribeiro S, McGowan CC, Jayathilake K, Castilho JL, Grangeiro A. Cardiovascular disease among people living with HIV in Brazil. Trop Med Int Health 2020; 25:886-896. [PMID: 32306480 PMCID: PMC7547667 DOI: 10.1111/tmi.13405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES There is a paucity of data on cardiovascular disease (CVD) among people living with HIV (PLHIV) in resource-limited countries. We assessed factors associated with CVD and the impact of prevalent CVD on all-cause mortality in PLHIV on antiretroviral therapy in Brazil. METHODS Competing risk regression to assess factors associated with CVD and all-cause mortality in the HIV-Brazil Cohort Study between 2003 and 2014. RESULTS Among 5614 patients, the rate of CVD was 3.5 (95% confidence interval [95% CI] 2.9-4.3) per 1000 person-years. CVD was associated with older age (adjusted hazard ratio [aHR] 6.4 for ≥55 years vs. <35 years, 95% CI: 2.5-16.3, P < 0.01), black race (aHR 1.8 vs. white race, 95% CI: 1.0-3.1, P = 0.04), past CVD (aHR 3.0 vs. no past CVD, 95% CI: 1.4-6.2, P < 0.01), hypertension (aHR 1.8 vs. no hypertension, 95% CI: 1.0-3.1, P = 0.04), high-grade dyslipidemia (aHR 9.3 vs. no high-grade dyslipidemia, 95% CI: 6.0-14.6, P < 0.01), ever smoking (aHR 2.4 vs. never, 95% CI: 1.2-5.0, P = 0.02) and low nadir CD4 cell count (aHR 1.8 for 100-250 cells/mm3 vs. >250 cells/mm3 , 95% CI: 1.0-3.2, P = 0.05). The rate of death was 16.6 (95% CI: 15.1-18.3) per 1000 person-years. Death was strongly associated with having had a past CVD event (aHR 1.7 vs. no past CVD event, 95% CI: 1.1-2.7, P = 0.01). CONCLUSIONS Traditional and HIV-specific factors associated with CVD among PLHIV in Brazil are similar to those identified among PLHIV in high-income countries. PLHIV in Brazil with a history of CVD have a high risk of death. CVD care and treatment remain priorities for PLHIV in Brazil as this population ages and antiretroviral therapy use expands.
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Affiliation(s)
- David C. Boettiger
- Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Matthew G. Law
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Valdiléa Veloso
- National Institute of Infectology – Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Rosa A. Souza
- São Paulo State Department of Health, AIDS Reference and Training Center, São Paulo, Brazil
| | - Maria L. R. Ikeda
- School of Health, University do Vale do Rio dos Sinos, Porto Alegre, Brazil
| | - Paulo R. deAlencastro
- Care and Treatment Clinic of the Hospital Sanatório Partenon, Rio Grande do Sul State Department of Health, Porto Alegre, Brazil
| | - Unai Tupinambás
- Medical School, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Carlos Brites
- Edgar Santos University Hospital Complex, Federal University of Bahia, Salvador, Brazil
| | - Beatriz Grinsztejn
- National Institute of Infectology – Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Jackeline O. Ggomes
- São Paulo State Department of Health, Institute of Health, São Paulo, Brazil
| | - Sayonara Ribeiro
- National Institute of Infectology – Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Catherine C. McGowan
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karu Jayathilake
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica L. Castilho
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandre Grangeiro
- Department of Preventive Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
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23
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Ostermann J, Mühlbacher A, Brown DS, Regier DA, Hobbie A, Weinhold A, Alshareef N, Derrick C, Thielman NM. Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:851-861. [PMID: 32762986 DOI: 10.1016/j.jval.2020.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Limited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making. METHODS A discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models. RESULTS Most participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics. CONCLUSION Overall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services, Policy and Management, University of South Carolina, Columbia, SC, USA
| | - Axel Mühlbacher
- Institute of Health Economics and Healthcare Management, Hochschule Neubrandenburg, Neubrandenburg, Germany
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Dean A Regier
- Cancer Research Centre, University of British Columbia, Vancouver, BC, Canada
| | - Amy Hobbie
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Andrew Weinhold
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Noor Alshareef
- Department of Health Services, Policy and Management, University of South Carolina, Columbia, SC, USA
| | - Caroline Derrick
- Department of Medicine, University of South Carolina, Columbia, SC, USA
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24
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Schaefer JH, Stephan C, Foerch C, Pfeilschifter W. Ischemic stroke in human immunodeficiency virus-positive patients: An increasingly age-related comorbidity? Eur Stroke J 2020; 5:252-261. [PMID: 33072879 DOI: 10.1177/2396987320927672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 04/28/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction The global incidence of ischemic stroke among patients with human immunodeficiency virus is increasing. The aim of this controlled case analysis was to study patient characteristics, stroke etiologies, and risk factors in human immunodeficiency virus-positive patients in a medical system with easy access to antiretroviral therapies. Patients and methods We conducted a retrospective, observational study of human immunodeficiency virus-positive patients treated in our stroke unit and outpatient clinic in Germany between 2012 and 2018. A control group of all patients treated for acute ischemic stroke in 2018 was used to elicit possible differences in stroke localization, etiology, and distribution of risk factors. Results Out of 3615 patients with an acute ischemic stroke, 24 (0.7%) were newly or previously diagnosed as human immunodeficiency virus-positive. Strokes in this cohort were caused by large-vessel disease (37.5%), small-vessel disease (20.8%), cryptogenic-embolism (20.8%), vasculitis (16.7%), and cardio-embolism (4.2%). Large-vessel disease-related strokes were more often located in the posterior circulation (77.8%). Compared to the control group, cardio-embolic strokes were less and vasculitis and large-vessel disease more frequent. Human immunodeficiency virus-positive patients were younger at stroke onset (53.7 ± 12.8 vs. 70.2 ± 14.6 years, p = 0.05). Discussion Although the prevalence of human immunodeficiency virus-infection among patients treated for acute ischemic strokes appears low, this collective merits special attention due to a high burden of potentially modifiable risk factors and vasculitis. Conclusion Compared to previous studies, age at stroke onset was one of the highest, supporting the hypothesis that as antiretroviral therapy increases the life expectancy of people living with HIV/AIDS, they will be increasingly affected by cardiovascular disease. Human immunodeficiency virus-related cerebral vasculitis was associated with high mortality (75%).
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Affiliation(s)
- Jan H Schaefer
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
| | - Christoph Stephan
- Department of Internal Medicine, Infectious Diseases Division, Goethe University, Frankfurt am Main, Germany
| | - Christian Foerch
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
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25
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Association of HIV Infection and Antiretroviral Therapy With Sudden Cardiac Death. J Acquir Immune Defic Syndr 2020; 82:468-474. [PMID: 31714425 DOI: 10.1097/qai.0000000000002161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND HIV infection potentially increases coronary artery disease and heart failure risks. However, the association between HIV infection and sudden cardiac death (SCD) has not been extensively studied. This nationwide cohort study aimed to determine SCD risks in Taiwanese patients with and without HIV infection. METHODS Adult people living with HIV/AIDS (PLWHA) since January 1, 2003, were identified from the Taiwan Centers for Disease Control HIV surveillance system. HIV-infected individuals were defined as positive HIV-1 Western blot. A control cohort without HIV infection, matched for age and sex, was selected for comparison from the Taiwan National Health Insurance Research Database. All patients were followed up until SCD, mortality for another cause, or till December 31, 2014. A time-dependent Cox proportional hazards model was used to determine the association of HIV and antiretroviral therapy (ART) with SCD. RESULTS During a mean 5.86-year follow-up, 5342 (4.40%) of 121,530 patients (24,306 PLWHA and 97,224 matched controls) died; among them, 150 (0.12%) died of SCD. Among 150 SCD events, 97 (64.7%) and 53 (33.3%) occurred in PLWHA and controls, respectively, which corresponded to incidences of 68.31 in PLWHA and 9.31 per 100,000 person-years in controls (P < 0.001). After adjusting for age, sex, and comorbidities, HIV infection was an independent risk factor for SCD (adjusted hazard ratio, 8.15; 95% confidence interval: 5.58 to 11.90). SCD incidence was significantly lower in PLWHA receiving ART (adjusted hazard ratio 0.53; 95% confidence interval: 0.32 to 0.87). CONCLUSIONS HIV infection is an independent risk factor for SCD. SCD rates are low in PLWHA receiving ART.
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Seneviratne HK, Hamlin AN, Heck CJS, Bumpus NN. Spatial Distribution Profiles of Emtricitabine, Tenofovir, Efavirenz, and Rilpivirine in Murine Tissues Following In Vivo Dosing Correlate with Their Safety Profiles in Humans. ACS Pharmacol Transl Sci 2020; 3:655-665. [PMID: 32832868 PMCID: PMC7433710 DOI: 10.1021/acsptsci.0c00015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 02/08/2023]
Abstract
![]()
Emtricitabine (FTC), tenofovir (TFV),
efavirenz (EFV), and rilpivirine
(RPV) are currently used as components of HIV combination therapy.
Although these drugs are widely used in antiretroviral therapy, several
organ toxicities related to TFV and EFV have been observed clinically.
TFV is associated with nephrotoxicity, whereas EFV-related hepatotoxicity
and neurotoxicity have been reported. While the precise molecular
mechanisms related to the above-mentioned clinically observed toxicities
have yet to be elucidated, understanding the local tissue distribution
profiles of these drugs could yield insights into their safety profiles.
To date, the distributions of these drugs in tissue following in vivo exposure are poorly understood. Therefore, in this
study, we employed a matrix-assisted laser desorption/ionization mass
spectrometry imaging method to generate spatial distribution profiles
of FTC, TFV, EFV, and RPV in mouse tissues following in vivo dosing of following drug regimens: TFV–FTC–EFV and
TFV–FTC–RPV. For this study, liver, brain, kidney, spleen,
and heart tissues were obtained from mice (n = 3)
following separate oral administration of the above-mentioned drug
regimens. Interestingly, EFV was detected in liver, brain, and heart
following TFV–FTC–EFV treatment. Additionally, hydroxylated
EFV, which encompasses the cytochrome P450-dependent monooxygenated
metabolites of EFV, was detected in liver, brain, spleen, and heart
tissue sections. Notably, the tissue distribution profiles of RPV
and hydroxylated RPV following in vivo dosing of
TFV–FTC–RPV were different from EFV/hydroxylated EFV
despite RPV belonging to the same drug class as EFV. In conclusion,
the observed spatial distribution profiles of the study drugs are
in agreement with their safety profiles in humans.
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Affiliation(s)
- Herana Kamal Seneviratne
- Department of Medicine, Division of Clinical Pharmacology and Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - Allyson N Hamlin
- Department of Medicine, Division of Clinical Pharmacology and Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - Carley J S Heck
- Department of Medicine, Division of Clinical Pharmacology and Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - Namandjé N Bumpus
- Department of Medicine, Division of Clinical Pharmacology and Department of Pharmacology and Molecular Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
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Bowman E, Funderburg NT. Lipidome Abnormalities and Cardiovascular Disease Risk in HIV Infection. Curr HIV/AIDS Rep 2020; 16:214-223. [PMID: 30993515 DOI: 10.1007/s11904-019-00442-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Human immunodeficiency virus (HIV) infection and its treatment with antiretroviral therapy (ART) are associated with lipid abnormalities that may enhance cardiovascular disease risk (CVD). RECENT FINDINGS Chronic inflammation persists in HIV+ individuals, and complex relationships exist among lipids and inflammation, as immune activation may be both a cause and a consequence of lipid abnormalities in HIV infection. Advances in mass spectrometry-based techniques now allow for detailed measurements of individual lipid species; improved lipid measurement might better evaluate CVD risk compared with the prognostic value of traditional assessments. Lipidomic analyses have begun to characterize dynamic changes in lipid composition during HIV infection and following treatment with ART, and further investigation may identify novel lipid biomarkers predictive of adverse outcomes. Developing strategies to improve management of comorbidities in the HIV+ population is important, and statin therapy and lifestyle modifications, including diet and exercise, may help to improve lipid levels and mitigate CVD risk.
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Affiliation(s)
- Emily Bowman
- School of Health and Rehabilitation Sciences, Division of Medical Laboratory Science, Ohio State University College of Medicine, 453 W. 10th Ave. 535A Atwell Hall, Columbus, OH, 43210, USA
| | - Nicholas T Funderburg
- School of Health and Rehabilitation Sciences, Division of Medical Laboratory Science, Ohio State University College of Medicine, 453 W. 10th Ave. 535A Atwell Hall, Columbus, OH, 43210, USA.
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Treatment Bias in Management of HIV Patients Admitted for Acute Myocardial Infarction: Does It Still Exist? J Gen Intern Med 2020; 35:57-62. [PMID: 31713036 PMCID: PMC6957660 DOI: 10.1007/s11606-019-05416-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/30/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Previous studies have reported lower rates of coronary angiography and revascularization, and significantly higher mortality among patients infected with human immunodeficiency virus (HIV) presenting with acute myocardial infarction (AMI). This observational study was designed to evaluate characteristics and inpatient outcomes of patients with seropositive HIV infection presenting with AMI. METHODS Using the National Inpatient Sample (NIS) database, we identified patients (admissions) with a primary diagnosis of myocardial infarction and a co-occurring HIV. We described baseline characteristics and outcomes. Our primary outcomes of interest were prevalence of coronary angiography, revascularization (percutaneous coronary intervention (PCI) or CABG), and mortality. RESULTS From 2010 to 2014, of about 2,977,387 patients with a primary diagnosis of AMI, 10,907 (0.4%) were HIV seropositive. Patients with HIV were younger and more likely to be African American or Hispanic. Coronary angiography and revascularization were performed more frequently in the HIV population. The higher prevalence of revascularization was driven by a higher incidence of PCI. In a multivariable model, patients with HIV were no more likely to undergo revascularization than the general population. This was also the case for PCI. Unadjusted all-cause mortality was lower among patients with HIV. After controlling for confounders, this finding was not significant (OR 0.97, 95% CI 0.75-1.25, p = 0.79). The length of stay between both groups was comparable. CONCLUSION In this current analysis, we did not note any treatment bias or difference in the rate of in-hospital total mortality for HIV-seropositive patients presenting with AMI compared with the general population.
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Reversible effect on lipids by switching from tenofovir disoproxil fumarate to tenofovir alafenamide and back. AIDS 2019; 33:2387-2391. [PMID: 31764103 DOI: 10.1097/qad.0000000000002350] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of the current study is to assess the effect of tenofovir alafenamide (TAF) and tenofovir disoproxil fumarate (TDF) on lipids in patients switching from TDF to TAF and back. METHODS Retrospective data collection on patients who were initially switched from TDF to TAF and switched back to TDF after generics of TDF became available. RESULTS In total, 385 patients were included. Median duration of TDF exposure before switch was 317 weeks (interquartile range 172-494). After switching from TDF to TAF, mean total cholesterol (TC) increased from 186 ± 37 mg/dl at baseline to 206 ± 43 and 204 ± 43 mg/dl at weeks 12 and 24 (P < 0.001). The increase in TC was mainly due to an increase in LDL cholesterol. However, ratio of TC/HDL remained unchanged, indicating a simultaneous rise of LDL and HDL cholesterol. Baseline triglycerides increased from mean 153 ± 96 to 176 ± 120 and 176 ± 124 mg/dl at weeks, 12 and 24 (P < 0.001). From 385 patients 168 were switched back from TAF to TDF after median duration on TAF of 96 weeks (interquartile range 89-104). At switching back from TAF to TDF, mean TC was 202 ± 40 mg/dl and decreased at weeks 12 and 24 to 183 ± 41 and 185 ± 35 mg/dl (P < 0.001). Mean triglycerides were 163 ± 119 mg/dl and decreased to 145 ± 108 and 157 ± 112 mg/dl, respectively (P < 0.05). Patients with higher increases in TC after switching from TDF to TAF also showed more pronounced decreases after switching back. CONCLUSION The results demonstrate a reversible effect on lipids by switching from TDF to TAF and back.
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Distinct inflammatory profiles in HIV-infected individuals under antiretroviral therapy using cannabis, cocaine or cannabis plus cocaine. AIDS 2019; 33:1831-1842. [PMID: 31490211 DOI: 10.1097/qad.0000000000002296] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To evaluate the effects of cannabis and/or cocaine use on inflammatory, oxidative stress status and circulating monocyte subsets in HIV-infected individuals under antiretroviral therapy. DESIGN Soluble CD14 (sCD14), intestinal fatty acid-binding protein (IFABP), tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-8, IL-10, C-reactive protein (CRP) and oxidative stress markers were examined. The monocyte subsets and their activation and cytokine production by peripheral blood mononuclear cells (PBMCs) of HIV-1 infected individuals upon lipopolysaccharide (LPS)-stimulation were also investigated. METHODS sCD14, IFABP, TNF-α, IL-6, IL-8 and IL-10 levels were evaluated using ELISA, CRP by turbidimetry; lipid peroxidation (TBARS) spectrofluometrically and total thiol levels by using 5-5'-dithio-bis (2-nitrobenzoic acid) reagent. Monocyte subsets and activation were assessed by flow cytometry. RESULTS All HIV-infected drug user groups showed higher sCD14 levels compared with HIV+ nondrug users. IFABP was increased in HIV+ drug-users in relation to healthy individuals. Cannabis use lowered the percentages of inflammatory, nonclassical, activated-classic and activated-inflammatory monocytes. Cocaine users showed increased plasmatic TNF-α and TBARS levels, decreased thiols content and lower activated-classic and inflammatory-monocyte percentages. Cannabis-plus-cocaine use increased CRP, IL-8 and IL-6/IL-10 ratio, but decreased thiol content, and inflammatory and activated-classic monocyte percentages. PBMCs of cannabis and cannabis-plus-cocaine users showed low-potential cytokine production either spontaneously or under LPS-stimulation. CONCLUSION In HIV infection, the use of cannabis induces predominantly an anti-inflammatory profile. The use of cocaine and cannabis-plus-cocaine showed a mixed pro-inflammatory and anti-inflammatory profile, with predominance of inflammatory status. Further studies are required to better understand the action of these drugs in HIV infection.
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Eyawo O, Brockman G, Goldsmith CH, Hull MW, Lear SA, Bennett M, Guillemi S, Franco-Villalobos C, Adam A, Mills EJ, Montaner JSG, Hogg RS. Risk of myocardial infarction among people living with HIV: an updated systematic review and meta-analysis. BMJ Open 2019; 9:e025874. [PMID: 31551371 PMCID: PMC6773316 DOI: 10.1136/bmjopen-2018-025874] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 08/14/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Cardiovascular disease (CVD) is one of the leading non-AIDS-defining causes of death among HIV-positive (HIV+) individuals. However, the evidence surrounding specific components of CVD risk remains inconclusive. We conducted a systematic review and meta-analysis to synthesise the available evidence and establish the risk of myocardial infarction (MI) among HIV+ compared with uninfected individuals. We also examined MI risk within subgroups of HIV+ individuals according to exposure to combination antiretroviral therapy (ART), ART class/regimen, CD4 cell count and plasma viral load (pVL) levels. DESIGN Systematic review and meta-analysis. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews until 18 July 2018. Furthermore, we scanned recent HIV conference abstracts (CROI, IAS/AIDS) and bibliographies of relevant articles. ELIGIBILITY CRITERIA Original studies published after December 1999 and reporting comparative data relating to the rate of MI among HIV+ individuals were included. DATA EXTRACTION AND SYNTHESIS Two reviewers working in duplicate, independently extracted data. Data were pooled using random-effects meta-analysis and reported as relative risk (RR) with 95% CI. RESULTS Thirty-two of the 8130 identified records were included in the review. The pooled RR suggests that HIV+ individuals have a greater risk of MI compared with uninfected individuals (RR: 1.73; 95% CI 1.44 to 2.08). Depending on risk stratification, there was moderate variation according to ART uptake (RR, ART-treated=1.80; 95% CI 1.17 to 2.77; ART-untreated HIV+ individuals: 1.25; 95% CI 0.93 to 1.67, both relative to uninfected individuals). We found low CD4 count, high pVL and certain ART characteristics including cumulative ART exposure, any/cumulative use of protease inhibitors as a class, and exposure to specific ART drugs (eg, abacavir) to be importantly associated with a greater MI risk. CONCLUSIONS Our results indicate that HIV infection, low CD4, high pVL, cumulative ART use in general including certain exposure to specific ART class/regimen are associated with increased risk of MI. The association with cumulative ART may be an index of the duration of HIV infection with its attendant inflammation, and not entirely the effect of cumulative exposure to ART per se. PROSPERO REGISTRATION NUMBER CRD42014012977.
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Affiliation(s)
- Oghenowede Eyawo
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Faculty of Health, York University, Toronto, ON, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Gwenyth Brockman
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles H Goldsmith
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Burnaby, British Columbia, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Mark W Hull
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Healthy Heart Program, St. Paul's Hospital, Providence Health Care, Vancouver, British Columbia, Canada
| | - Matthew Bennett
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | - Ahmed Adam
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Edward J Mills
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert S Hogg
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
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Randomized study evaluating the efficacy and safety of switching from an an abacavir/lamivudine-based regimen to an elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide single-tablet regimen. AIDS 2019; 33:1583-1593. [PMID: 31305329 DOI: 10.1097/qad.0000000000002244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of switching from an abacavir/lamivudine (ABC/3TC)-based regimen to an elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) single-tablet regimen in virologically suppressed, HIV-1-infected adults. DESIGN Randomized, open-label, noninferiority study. METHODS Participants with HIV-1 RNA levels less than 50 copies/ml receiving ABC/3TC plus a third agent for at least 6 months were randomized 2 : 1 to switch immediately to E/C/F/TAF (immediate-switch group) for 48 weeks or to continue receiving ABC/3TC plus a third agent for 24 weeks followed by E/C/F/TAF for 24 weeks (delayed-switch group). The primary endpoint was HIV-1 RNA less than 50 copies/ml at Week 24 by Food and Drug Administration Snapshot algorithm (-12% noninferiority margin). RESULTS Baseline characteristics of 274 participants (183 in immediate-switch group and 91 in delayed-switch group) were similar. Virologic response was maintained at Week 24 by 93.4 and 97.8% of participants in the immediate-switch and delayed-switch groups, respectively, with a treatment difference of -4.4% (95% confidence interval: -9.4 to 1.9%), confirming noninferiority. Adverse events of any grade were similar between groups through Week 24 (66% E/C/F/TAF, 64% ABC/3TC); adverse event-related drug discontinuations occurred in 4% of participants switching to E/C/F/TAF (no discontinuations because of renal events) and no participants continuing ABC/3TC. Renal biomarkers of urine albumin:creatinine and beta-2-microglobulin:creatinine ratios significantly improved on E/C/F/TAF. Self-reported treatment satisfaction was significantly higher with E/C/F/TAF. CONCLUSION Switching to E/C/F/TAF was noninferior to continuing ABC/3TC plus a third agent for maintenance of HIV RNA suppression at Week 24. This study supports E/C/F/TAF as an efficacious and well tolerated option for participants switching from ABC/3TC-based regimens.
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Chou R, Dana T, Grusing S, Bougatsos C. Screening for HIV Infection in Asymptomatic, Nonpregnant Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 321:2337-2348. [PMID: 31184705 DOI: 10.1001/jama.2019.2592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Untreated HIV infection can result in significant morbidity, mortality, and HIV transmission. A 2012 review for the US Preventive Services Task Force (USPSTF) found antiretroviral therapy (ART) associated with improved clinical outcomes and decreased transmission risk in persons with CD4 cell counts less than 500/mm3. OBJECTIVE To update the 2012 review on HIV screening to inform the USPSTF. DATA SOURCES Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2012 to June 2018, with surveillance through January 2019. STUDY SELECTION Nonpregnant individuals 12 years and older; randomized clinical trials (RCTs) and controlled observational studies of screening vs no screening, alternative screening strategies, earlier vs later initiation of ART, and long-term harms of ART. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. MAIN OUTCOMES AND MEASURES Mortality, AIDS events, quality of life, function, and HIV transmission; harms of screening and long-term (≥2 years) harms of ART; screening yield. RESULTS Eighteen new studies (5 RCTs, 11 cohort studies, and 2 systematic reviews; N = 266 563) were included, and 11 studies (2 RCTs and 9 cohort studies; N = 218 542) were carried forward from the prior USPSTF report. No study directly evaluated effects of HIV screening vs no screening on clinical outcomes or harms, or the yield of alternative screening strategies. Two newly identified RCTs conducted completely or partially in low-resource settings found ART initiation at CD4 cell counts greater than 500/mm3 associated with lower risk of a composite outcome of mortality, AIDS-defining events, or serious non-AIDS events (relative risk [RR], 0.44 [95% CI, 0.31-0.63] and RR, 0.57 [95% CI, 0.35-0.95]); results were consistent with those from a large observational study. Early ART was not associated with increased risk of cardiovascular events. Early ART initiation was associated with sustained reduction in risk of HIV transmission at 5.5 years (RR, 0.07 [95% CI, 0.02-0.22] for linked transmission). New evidence regarding the association between abacavir use and risk of cardiovascular events was inconsistent. Certain antiretroviral regimens were associated with increased risk of long-term neuropsychiatric, renal, hepatic, and bone adverse events. CONCLUSIONS AND RELEVANCE In nonpregnant adolescents and adults there was no direct evidence on the clinical benefits and harms of screening for HIV infections vs no screening, or the yield of repeat or alternative screening strategies. New evidence extends effectiveness of ART to asymptomatic individuals with CD4 cell counts greater than 500/mm3 and shows sustained reduction in risk of HIV transmission at longer-term follow-up, although certain ART regimens may be associated with increased risk of long-term harms.
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Affiliation(s)
- Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
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Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Curry SJ, Doubeni CA, Epling JW, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for HIV Infection: US Preventive Services Task Force Recommendation Statement. JAMA 2019; 321:2326-2336. [PMID: 31184701 DOI: 10.1001/jama.2019.6587] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
IMPORTANCE Approximately 1.1 million persons in the United States are currently living with HIV, and more than 700 000 persons have died of AIDS since the first cases were reported in 1981. There were approximately 38 300 new diagnoses of HIV infection in 2017. The estimated prevalence of HIV infection among persons 13 years and older in the United States is 0.4%, and data from the Centers for Disease Control and Prevention show a significant increase in HIV diagnoses starting at age 15 years. An estimated 8700 women living with HIV give birth each year in the United States. HIV can be transmitted from mother to child during pregnancy, labor, delivery, and breastfeeding. The incidence of perinatal HIV infection in the United States peaked in 1992 and has declined significantly following the implementation of routine prenatal HIV screening and the use of effective therapies and precautions to prevent mother-to-child transmission. OBJECTIVE To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on screening for HIV infection in adolescents, adults, and pregnant women. EVIDENCE REVIEW The USPSTF reviewed the evidence on the benefits and harms of screening for HIV infection in nonpregnant adolescents and adults, the yield of screening for HIV infection at different intervals, the effects of initiating antiretroviral therapy (ART) at a higher vs lower CD4 cell count, and the longer-term harms associated with currently recommended ART regimens. The USPSTF also reviewed the evidence on the benefits (specifically, reduced risk of mother-to-child transmission of HIV infection) and harms of screening for HIV infection in pregnant persons, the yield of repeat screening for HIV at different intervals during pregnancy, the effectiveness of currently recommended ART regimens for reducing mother-to-child transmission of HIV infection, and the harms of ART during pregnancy to the mother and infant. FINDINGS The USPSTF found convincing evidence that currently recommended HIV tests are highly accurate in diagnosing HIV infection. The USPSTF found convincing evidence that identification and early treatment of HIV infection is of substantial benefit in reducing the risk of AIDS-related events or death. The USPSTF found convincing evidence that the use of ART is of substantial benefit in decreasing the risk of HIV transmission to uninfected sex partners. The USPSTF also found convincing evidence that identification and treatment of pregnant women living with HIV infection is of substantial benefit in reducing the rate of mother-to-child transmission. The USPSTF found adequate evidence that ART is associated with some harms, including neuropsychiatric, renal, and hepatic harms, and an increased risk of preterm birth in pregnant women. The USPSTF concludes with high certainty that the net benefit of screening for HIV infection in adolescents, adults, and pregnant women is substantial. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends screening for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk of infection should also be screened. (A recommendation) The USPSTF recommends screening for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. (A recommendation).
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Affiliation(s)
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | - Karina W Davidson
- Feinstein Institute for Medical Research at Northwell Health, Manhasset, New York
| | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | | | - Lori Pbert
- University of Massachusetts Medical School, Worcester
| | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
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Desai M, Montez-Rath ME, Kapphahn K, Joyce VR, Mathur MB, Garcia A, Purington N, Owens DK. Missing data strategies for time-varying confounders in comparative effectiveness studies of non-missing time-varying exposures and right-censored outcomes. Stat Med 2019; 38:3204-3220. [PMID: 31099433 DOI: 10.1002/sim.8174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 01/12/2023]
Abstract
The treatment of missing data in comparative effectiveness studies with right-censored outcomes and time-varying covariates is challenging because of the multilevel structure of the data. In particular, the performance of an accessible method like multiple imputation (MI) under an imputation model that ignores the multilevel structure is unknown and has not been compared to complete-case (CC) and single imputation methods that are most commonly applied in this context. Through an extensive simulation study, we compared statistical properties among CC analysis, last value carried forward, mean imputation, the use of missing indicators, and MI-based approaches with and without auxiliary variables under an extended Cox model when the interest lies in characterizing relationships between non-missing time-varying exposures and right-censored outcomes. MI demonstrated favorable properties under a moderate missing-at-random condition (absolute bias <0.1) and outperformed CC and single imputation methods, even when the MI method did not account for correlated observations in the imputation model. The performance of MI decreased with increasing complexity such as when the missing data mechanism involved the exposure of interest, but was still preferred over other methods considered and performed well in the presence of strong auxiliary variables. We recommend considering MI that ignores the multilevel structure in the imputation model when data are missing in a time-varying confounder, incorporating variables associated with missingness in the MI models as well as conducting sensitivity analyses across plausible assumptions.
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Affiliation(s)
- Manisha Desai
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Palo Alto, California
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California
| | - Kristopher Kapphahn
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Palo Alto, California
| | | | - Maya B Mathur
- Department of Biostatistics, Harvard University, Cambridge, Massachusetts
| | - Ariadna Garcia
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Palo Alto, California
| | - Natasha Purington
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Palo Alto, California
| | - Douglas K Owens
- VA Palo Alto Health Care System, Palo Alto, California.,Center for Health Policy/Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California
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Gwag T, Meng Z, Sui Y, Helsley RN, Park SH, Wang S, Greenberg RN, Zhou C. Non-nucleoside reverse transcriptase inhibitor efavirenz activates PXR to induce hypercholesterolemia and hepatic steatosis. J Hepatol 2019; 70:930-940. [PMID: 30677459 PMCID: PMC6462244 DOI: 10.1016/j.jhep.2018.12.038] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/17/2018] [Accepted: 12/23/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS The most prescribed non-nucleoside reverse transcriptase inhibitor, efavirenz, has been associated with elevated risk of dyslipidemia and hepatic steatosis in HIV-infected patients but the underlying mechanisms remain elusive. Herein, we investigated the role of pregnane X receptor (PXR) in mediating the adverse effects of efavirenz on lipid homeostasis. METHODS Cell-based reporter assays, primary cell culture, and multiple mouse models including conditional knockout and humanized mice were combined to study the impact of efavirenz on PXR activities and lipid homeostasis in vitro and in vivo. A novel liver-specific Pxr knockout mouse model was also generated to determine the contribution of hepatic PXR signaling to efavirenz-elicited dyslipidemia and hepatic steatosis. RESULTS We found that efavirenz is a potent PXR-selective agonist that can efficiently activate PXR and induce its target gene expression in vitro and in vivo. Treatment with efavirenz-induced hypercholesterolemia and hepatic steatosis in mice but deficiency of hepatic PXR abolished these adverse effects. Interestingly, efavirenz-mediated PXR activation regulated the expression of several key hepatic lipogenic genes including fatty acid transporter CD36 and cholesterol biosynthesis enzyme squalene epoxidase (SQLE), leading to increased lipid uptake and cholesterol biosynthesis in hepatic cells. While CD36 is a known PXR target gene, we identified a DR-2-type of PXR-response element in the SQLE promoter and established SQLE as a direct transcriptional target of PXR. Since PXR exhibits considerable differences in its pharmacology across species, we also confirmed these findings in PXR-humanized mice and human primary hepatocytes. CONCLUSIONS The widely prescribed antiretroviral drug efavirenz induces hypercholesterolemia and hepatic steatosis by activating PXR signaling. Activation of PXR should be taken into consideration for patients undergoing long-term treatment with PXR agonistic antiretroviral drugs. LAY SUMMARY Efavirenz is widely prescribed for HIV-infected patients but has some side effects. It can increase lipid levels in patients' blood and liver. Here we show that efavirenz can activate a unique liver protein called PXR which mediates the adverse effects of efavirenz on lipid levels in mouse models.
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Affiliation(s)
- Taesik Gwag
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Zhaojie Meng
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Yipeng Sui
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Robert N. Helsley
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Se-Hyung Park
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Shuxia Wang
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, Kentucky, USA
| | | | - Changcheng Zhou
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA.
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Stroke in HIV. Can J Cardiol 2018; 35:280-287. [PMID: 30825950 DOI: 10.1016/j.cjca.2018.11.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 12/26/2022] Open
Abstract
Stroke is a heterogeneous disease in persons living with human immunodeficiency virus (HIV). HIV is thought to increase the risk of stroke through both HIV-related and traditional stroke risk factors, which vary with respect to the patient's age and clinical characteristics. Numerous studies show that detectable viremia and immunosuppression increase the risk of stroke across all ages, whereas traditional risk factors are more common in the aging population with HIV. As persons living with HIV age and acquire traditional stroke risk factors, the prevalence of stroke will likely continue to increase. Large- and small-vessel disease are the most common causes of stroke, although it is important to evaluate for infectious etiology as well. Research regarding the management of stroke in patients with HIV is scant, and recommendations often parallel those for the general population. Treatment of HIV and effective reduction of traditional stroke risk factors is important to reduce the risk of stroke in persons living with HIV. Future research will help elucidate the pathophysiology of HIV and stroke risk, investigate sex differences in stroke risk, and evaluate the safety and benefits of standard stroke preventative measures and HIV-specific interventions in this population.
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Dorjee K, Choden T, Baxi SM, Steinmaus C, Reingold AL. Risk of cardiovascular disease associated with exposure to abacavir among individuals with HIV: A systematic review and meta-analyses of results from 17 epidemiologic studies. Int J Antimicrob Agents 2018; 52:541-553. [PMID: 30040992 PMCID: PMC7791605 DOI: 10.1016/j.ijantimicag.2018.07.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/21/2018] [Accepted: 07/14/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Abacavir's potential to cause cardiovascular disease (CVD) among people living with HIV (PLWH) is debated. We conduct a systematic review and meta-analyses to assess CVD risk from recent and cumulative abacavir exposure. METHODS We searched Medline, Embase, Web of Science, abstracts from Conference on Retroviruses and Opportunistic Infections, and International AIDS Society/AIDS Conferences and bibliographies of review articles to identify research studies published through 2018 on CVD risk associated with abacavir exposure among PLWH. Studies assessing risk of CVD associated with recent (exposure within last 6 months) or cumulative abacavir exposure across all age-groups were eligible. Risks were quantified using fixed- and random-effects models. RESULTS Of 378 unique citations, 68 full-text research articles and abstracts were reviewed. Seventeen studies assessed risk of CVD from recent or cumulative abacavir exposure. Summary relative risk (sRR) is increased for recent exposure (n=16 studies, sRR=1.61; 95% confidence interval: 1.48-1.75), higher in antiretroviral-therapy-naive population (n=5, 1.91; 1.48-2.46) and all studies reported RR>1. The sRR for recent exposure was similarly increased for the outcome of acute myocardial infarction, and for studies that adjusted for substance abuse, smoking, prior CVD, traditional CVD risk factors, and CD4 cell-count/HIV viral load. The sRR was increased for cumulative abacavir exposure (per year) (n=4, 1.12; 1.05-1.20) but no increase was seen after adjusting for recent exposure (n=5, 1.00; 0.93-1.08). CONCLUSIONS Our findings suggest an increased risk of CVD from recent abacavir exposure. The risk remained elevated after adjusting for potential confounders. Further investigations are needed to understand CVD risk from cumulative exposure.
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Affiliation(s)
- Kunchok Dorjee
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA; Center for Tuberculosis Research, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Tsering Choden
- School of Public Health, Department of Epidemiology and Biostatistics, State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Sanjiv M Baxi
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Craig Steinmaus
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Arthur L Reingold
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA
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Psichogiou M, Kapelios CJ, Konstantonis G, Argyris A, Nasothimiou E, Papadopoulou M, Kitas G, Papaioannou TG, Daikos GL, Sfikakis PP, Protogerou AD. Prevalence, Incidence, and Contributors of Subclinical Atheromatosis, Arteriosclerosis, and Arterial Hypertrophy in HIV-Infected Individuals: A Single-Center, 3-Year Prospective Study. Angiology 2018; 70:448-457. [PMID: 30235944 DOI: 10.1177/0003319718801093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiovascular disease (CVD) is an important comorbidity for people living with HIV infection (PLWH) in the combined antiretroviral therapy era. We prospectively examined the presence of subclinical arterial disease in 138 consecutive CVD-free, HIV-infected individuals compared to 664 HIV-negative individuals. We studied 10 arterial sites in 4 beds using 5 distinct biomarkers of subclinical atheromatosis, arteriosclerosis, and hypertrophy and evaluated the association of subclinical arterial damage with CVD-related and HIV-related factors at baseline and at 3-year follow-up. Atheromatosis, arteriosclerosis, and arterial hypertrophy were present in 36.1%, 59.7%, and 34.3% of HIV-infected individuals, respectively, at baseline. HIV infection was independently associated with carotid atheromatosis and hypertrophy. The presence of carotid atheromatosis was independently associated with age, years of smoking, and exposure to nonnucleoside reverse transcriptase inhibitors (NNRTIs). The annual incidence of atheromatosis, arteriosclerosis, and arterial hypertrophy was 5.5, 18.6, and 12.5 cases/100 patients, respectively. Carotid atheromatosis progression was significantly associated with NNRTI exposure. People living with HIV infection exhibited high prevalence and incidence of subclinical arterial damage and site-specific predilection for the carotids. These investigations may help optimize HIV-specific CVD prediction models. The NNRTIs may contribute to atheromatosis, emphasizing the need to consider the atherogenic potential of antiretroviral drugs in management strategies.
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Affiliation(s)
- Mina Psichogiou
- 1 First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University Athens School of Medicine, Athens, Greece
| | - Chris J Kapelios
- 2 Department of Cardiology, Laiko General Hospital, Athens, Greece
| | - Giorgos Konstantonis
- 3 First Department of Propaedeutic Medicine, Laiko General Hospital, National and Kapodistrian University Athens School of Medicine, Athens, Greece
| | - Antonis Argyris
- 4 Cardiovascular Prevention and Research Unit, Department of Pathophysiology, National and Kapodistrian University Athens School of Medicine, Athens, Greece
| | - Euthimia Nasothimiou
- 4 Cardiovascular Prevention and Research Unit, Department of Pathophysiology, National and Kapodistrian University Athens School of Medicine, Athens, Greece
| | - Martha Papadopoulou
- 1 First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University Athens School of Medicine, Athens, Greece
| | - George Kitas
- 5 Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Theodoros G Papaioannou
- 6 Biomedical Engineering Unit, First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George L Daikos
- 1 First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University Athens School of Medicine, Athens, Greece
| | - Petros P Sfikakis
- 3 First Department of Propaedeutic Medicine, Laiko General Hospital, National and Kapodistrian University Athens School of Medicine, Athens, Greece
| | - Athanase D Protogerou
- 4 Cardiovascular Prevention and Research Unit, Department of Pathophysiology, National and Kapodistrian University Athens School of Medicine, Athens, Greece
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Trevillyan JM, Wong G, Puls R, Petoumenos K, Emery S, Mellett NA, Mundra PA, Meikle PJ, Hoy JF. Changes in plasma lipidome following initiation of antiretroviral therapy. PLoS One 2018; 13:e0202944. [PMID: 30157268 PMCID: PMC6114786 DOI: 10.1371/journal.pone.0202944] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 08/13/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease and important changes in lipid metabolism. Advances in mass-spectrometry technology allow for the detailed assessment of individual lipid species which may illuminate the mechanisms underlying increased cardiovascular risk. We describe the change in plasma lipidome with initiation of antiretroviral therapy and compare these by regimen. METHODS Plasma lipid profiling (by electrospray isonisation-tandem mass spectrometry) was performed on ARV-naive HIV positive participants randomised to one of three regimens; tenofovir/emtricitabine with efavirenz, ritonavir-boosted atazanavir (atazanavir/r) or zidovudine/abacavir. Participants (n = 115) who remained on their randomised regimen with complete samples available at baseline, week 12 and 48 were included. 306 lipid species from 22 lipid classes were analysed. RESULTS Initiation of ART led to significant changes in lipidome which were partly dependent on the randomised regimen received. This led to significant differences in 72 lipid species and 7 classes (cholesterol ester, free cholesterol, phosphatidylcholine, GM3 ganglioside, trihexosylceramide, monohexosylceramide, and ceramides) by arm at week 48. Consistently higher lipid concentrations were seen with efavirenz compared with atazanavir/r or zidovudine/abacavir. Twelve of the lipid species and two lipid classes (cholesterol esters and ceramides) that were significantly increased in the efavirenz arm compared with the atazanavir/r or zidovudine/abacavir arms have previously been associated with future cardiovascular events in HIV positive patients. Change in HIV viral load was predictive of change in 3 lipid species. CONCLUSIONS Initiation of ART lead to significant changes in the plasma lipidome that were greatest in those receiving efavirenz.
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Affiliation(s)
- Janine M. Trevillyan
- Department of Infectious Diseases, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
- * E-mail:
| | - Gerard Wong
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Rebekah Puls
- Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | | | - Sean Emery
- The Kirby Institute, UNSW Sydney, Sydney, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | | | | | | | - Jennifer F. Hoy
- Department of Infectious Diseases, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Australia
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Geraci SA. Will Cardio-Virology Be the Next Cardio-Oncology? Am J Med 2018; 131:726-727. [PMID: 29425708 DOI: 10.1016/j.amjmed.2018.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/08/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Stephen A Geraci
- Departments of Internal Medicine and Medical Education, Quillen College of Medicine of East Tennessee State University, Johnson City.
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Abstract
PURPOSE OF REVIEW To summarize recent findings in the pathogenesis of ischemic heart disease (IHD) in people living with HIV (PLWH). RECENT FINDINGS PLWH have an elevated risk of IHD. Although incidence is declining, this condition still represents a major cause of non-AIDS-related mortality. The cause is likely multifactorial: traditional risk factors play an important role and IHD risk might be reduced with greater emphasis on primary prevention. The contribution of specific antiretroviral agents to IHD risk is changing as antiretroviral coverage increases globally and as safer agents have replaced drugs with well-described metabolic toxicities. The beneficial impact of virological suppression on antiretroviral therapy (ART) in reducing IHD is particularly evident in participants with advanced HIV infection and high baseline cardiovascular risk. The association between current abacavir use and myocardial infarction is still unexplained and indicates that mechanisms other than metabolic alterations may underlie IHD in PLWH. Consequently, the contributions of inflammation, subclinical atherosclerosis and endothelial dysfunction are receiving greater attention. SUMMARY Modern ART coupled with intensified efforts towards primary prevention is the cornerstone of IHD risk management in PLWH. The role of chronic inflammation and its optimal management need to be defined.
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Charnigo R, Khairy P, Guo J, Shohoudi A, Elayi CS. Use of digoxin in atrial fibrillation: One step further in the mortality controversy from the AFFIRM study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:713-719. [PMID: 29660142 DOI: 10.1111/pace.13350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/27/2018] [Accepted: 03/30/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whether there is a causal association between digoxin and mortality among patients with atrial fibrillation (AF), with or without congestive heart failure (HF), has been controversial; in particular, two prior analyses of data from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial have yielded conflicting results. We sought to investigate how digoxin impacts mortality, in the full AFFIRM cohort and for various subgroups, by applying marginal structural modeling (MSM) to AFFIRM data. METHODS MSM is a newer statistical approach, which estimates causal association in the absence of randomization. MSM more effectively accounts for time-varying treatment and mitigates potential biases, in contrast to the two statistical approaches used in prior analyses of the AFFIRM data. RESULTS Among 4,060 patients in AFFIRM, 660 (16.3%) died during follow-up. Digoxin was associated with significantly higher mortality in the full cohort (estimated hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.11-1.60, P = 0.002) and in 3,121 patients without HF (HR 1.36, 95% CI 1.07-1.72, P = 0.011). There was a trend toward higher mortality with digoxin in 939 patients with HF (HR 1.29, 95% CI 0.96-1.72, P = 0.090). Associations were nonsignificant in 463 patients with HF and left ventricular ejection fraction (EF) ≥40% and in 155 patients with EF ≤30%. CONCLUSIONS Digoxin is associated with significantly increased mortality among AFFIRM patients collectively, as determined by MSM statistical methodology. However, the impact of digoxin among AFFIRM patients with coexisting HF is inconclusive.
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Affiliation(s)
- Richard Charnigo
- Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Paul Khairy
- Montreal Heart Institute, Montreal, QC, Canada
| | - Jing Guo
- Health and Community Services Department, California State University Chico, Chico, CA, USA
| | | | - Claude S Elayi
- Cardiovascular Medicine, Gill Heart Institute, Lexington, KY, USA
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Elion RA, Althoff KN, Zhang J, Moore RD, Gange SJ, Kitahata MM, Crane HM, Drozd DR, Stein JH, Klein MB, Eron JJ, Silverberg MJ, Mathews WC, Justice AC, Sterling TR, Rabkin CS, Mayor AM, Klein DB, Horberg MA, Bosch RJ, Eyawo O, Palella FJ. Recent Abacavir Use Increases Risk of Type 1 and Type 2 Myocardial Infarctions Among Adults With HIV. J Acquir Immune Defic Syndr 2018; 78:62-72. [PMID: 29419568 PMCID: PMC5889316 DOI: 10.1097/qai.0000000000001642] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is persistent confusion as to whether abacavir (ABC) increases the risk of myocardial infarction (MI), and whether such risk differs by type 1 (T1MI) or 2 (T2MI) MI in adults with HIV. METHODS Incident MIs in North American Cohort Collaboration on Research and Design participants were identified from 2001 to 2013. Discrete time marginal structural models addressed channeling biases and time-dependent confounding to estimate crude hazard ratio (HR) and adjusted hazard ratio (aHR) and 95% confidence intervals; analyses were performed for T1MI and T2MI separately. A sensitivity analysis evaluated whether Framingham risk score (FRS) modified the effect of ABC on MI occurrence. RESULTS Eight thousand two hundred sixty-five adults who initiated antiretroviral therapy contributed 29,077 person-years and 123 MI events (65 T1MI and 58 T2MI). Median follow-up time was 2.9 (interquartile range 1.4-5.1) years. ABC initiators were more likely to have a history of injection drug use, hepatitis C virus infection, hypertension, diabetes, impaired kidney function, hyperlipidemia, low (<200 cells/mm) CD4 counts, and a history of AIDS. The risk of the combined MI outcome was greater for persons who used ABC in the previous 6 months [aHR = 1.84 (1.17-2.91)]; and persisted for T1MI (aHR = 1.62 [1.01]) and T2MI [aHR = 2.11 (1.08-4.29)]. FRS did not modify the effect of ABC on MI (P = 0.14) and inclusion of FRS in the MSM did not diminish the effect of recent ABC use on the combined outcome. CONCLUSIONS Recent ABC use was associated with MI after adjustment for known risk factors and for FRS. However, screening for T1MI risks may not identify all or even most persons at risk of ABC use-associated MIs.
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Affiliation(s)
- Richard A Elion
- Department of Medicine, George Washington University School of Medicine, Washington, DC
- Department of Infectious Disease, Providence Hospital, Washington, DC
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jinbing Zhang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Richard D Moore
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Stephen J Gange
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mari M Kitahata
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Heidi M Crane
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Daniel R Drozd
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - James H Stein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Marina B Klein
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Division of Infectious Diseases and Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada
| | - Joseph J Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - William C Mathews
- Department of Medicine, University of California San Diego, San Diego, CA
| | - Amy C Justice
- Division of General Internal Medicine, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Timothy R Sterling
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Charles S Rabkin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Angel M Mayor
- Department of Internal Medicine, Universidad Central del Caribe, School of Medicine, Bayamon, PR
| | - Daniel B Klein
- Department of Infectious Diseases, San Leandro Medical Center, Kaiser Permanente Northern California, San Leandro, CA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Ronald J Bosch
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Oghenowede Eyawo
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
| | - Frank J Palella
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL
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Ogunbayo GO, Bidwell K, Misumida N, Ha LD, Abdel-Latif A, Elayi CS, Smyth S, Messerli AW. Sex differences in the contemporary management of HIV patients admitted for acute myocardial infarction. Clin Cardiol 2018; 41:488-493. [PMID: 29672871 DOI: 10.1002/clc.22902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Studies have reported sex differences in the management of patients with acute myocardial infarction (AMI) in the general population. This observational study is designed to evaluate whether sex differences exist in the contemporary management of human immunodeficiency virus (HIV) patients admitted for diagnosis of AMI. HYPOTHESIS There is no difference in management of HIV patients with AMI. METHODS Using the National Inpatient Sample database, we identified patients with a primary diagnosis of AMI and a secondary diagnosis of HIV. We described baseline characteristics and outcomes using NIS documentation. Our primary areas of interest were revascularization and mortality. RESULTS Among 2 977 387 patients presenting from 2010 to 2014 with a primary diagnosis of AMI, 10907 (0.4%) had HIV (mean age, 54.1 ± 9.3 years; n = 2043 [18.9%] female). Females were younger, more likely to be black, and more likely to have hypertension, diabetes, obesity, and anemia. Although neither males nor females were more likely to undergo coronary angiography in multivariate analysis, revascularization was performed less frequently in females than in males (45.4% vs 62.7%; P < 0.01), driven primarily by lower incidence of PCI. In a multivariate model, females were less likely to undergo revascularization (OR: 0.59, 95% CI: 0.45-0.78, P < 0.01), a finding driven solely by PCI (OR: 0.64, 95% CI: 0.49-0.83, P < 0.01). All-cause mortality was similar in both groups. CONCLUSIONS AMI was more common in males than females with HIV. Females with HIV were more likely to be younger and black and less likely to be revascularized by PCI.
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Affiliation(s)
- Gbolahan O Ogunbayo
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington
| | - Katrina Bidwell
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington
| | - Naoki Misumida
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington
| | - Le Dung Ha
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Ahmed Abdel-Latif
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington
| | - Claude S Elayi
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington
| | - Susan Smyth
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington
| | - Adrian W Messerli
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington
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Dorjee K, Baxi SM, Reingold AL, Hubbard A. Risk of cardiovascular events from current, recent, and cumulative exposure to abacavir among persons living with HIV who were receiving antiretroviral therapy in the United States: a cohort study. BMC Infect Dis 2017; 17:708. [PMID: 29078761 PMCID: PMC5660446 DOI: 10.1186/s12879-017-2808-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/23/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is ongoing controversy regarding abacavir use in the treatment of HIV infection and the risk of subsequent development of cardiovascular disease. It is unclear how the risk varies as exposure accumulates. METHODS Using an administrative health-plan dataset, risk of cardiovascular disease events (CVDe), defined as the first episode of an acute myocardial infarction or a coronary intervention procedure, associated with abacavir exposure was assessed among HIV-infected individuals receiving antiretroviral therapy across the U.S. from October 2009 through December 2014. The data were longitudinal, and analyzed using marginal structural models. RESULTS Over 114,470 person-years (n = 72,733) of ART exposure, 714 CVDe occurred at an incidence rate (IR) (95% CI) of 6·23 (5·80, 6·71)/1000 person-years. Individuals exposed to abacavir had a higher IR of CVDe of 9·74 (8·24, 11·52)/1000 person-years as compared to 5·75 (5·30, 6·24)/1000 person-years for those exposed to other antiretroviral agents. The hazard (HR; 95% CI) of CVDe was increased for current (1·43; 1·18, 1·73), recent (1·41; 1·16, 1·70), and cumulative [(1·18; 1·06, 1·31) per year] exposure to abacavir. The risk for cumulative exposure followed a bell-shaped dose-response curve peaking at 24-months of exposure. Risk was similarly elevated among participants free of pre-existing heart disease or history of illicit substance use at baseline. CONCLUSION Current, recent, and cumulative use of abacavir was associated with an increased risk of CVDe. The findings were consistent irrespective of underlying cardiovascular risk factors.
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Affiliation(s)
- Kunchok Dorjee
- Division of Epidemiology, School of Public Health, University of California Berkeley, Hall Berkeley, 101 Haviland, CA, 94720-7358, USA.
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Sanjiv M Baxi
- Division of Epidemiology, School of Public Health, University of California Berkeley, Hall Berkeley, 101 Haviland, CA, 94720-7358, USA
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Arthur L Reingold
- Division of Epidemiology, School of Public Health, University of California Berkeley, Hall Berkeley, 101 Haviland, CA, 94720-7358, USA
| | - Alan Hubbard
- Division of Epidemiology, School of Public Health, University of California Berkeley, Hall Berkeley, 101 Haviland, CA, 94720-7358, USA
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, USA
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Lacson JCA, Barnes RP, Bahrami H. Coronary Artery Disease in HIV-Infected Patients: Downside of Living Longer. Curr Atheroscler Rep 2017; 19:18. [PMID: 28265887 DOI: 10.1007/s11883-017-0651-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Introduction of combination antiretroviral therapy (ART) has increased the life expectancy of patients with HIV infection, allowing them to live longer with this chronic medical condition and consequently experiencing conditions such as cardiovascular diseases (CVDs). Several studies have investigated the increased risk of CVD in people living with HIV (PLWH). However, less is known about the exact mechanisms involved in this increased risk. Also, specific guidelines for management of CVD in PLWH have not been developed yet. In this article, we review the recent literature on the mechanisms involved in pathogenesis of CVD in PLWH, with an emphasis on coronary artery disease (CAD). RECENT FINDINGS Although initial studies suspected the increased prevalence of traditional CVD risk factors and side effects of ART to be involved in the increased CVD risk in PLWH, recent studies have uncovered the important role of chronic persistent inflammation in this increased risk. In addition, biomarkers of inflammation have been associated with both CVD events and subclinical CAD in this population. Lastly, recent studies and ongoing clinical trials have been investigating medical interventions that aim to reduce inflammation and cardiovascular events. Different mechanisms of inflammation have been examined in PLWH, including subclinical viremia, microbial translocation, and coinfection with other pathogens such as cytomegalovirus. Although inflammatory biomarkers have been consistently associated with CVD and subclinical CVD outcomes, their prognostic value is unknown. Recent and ongoing trials are exploring the benefits of anti-inflammatory drugs, statins, and antimicrobial translocation drugs on both inflammation and CVD risk among PLWH.
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Affiliation(s)
- John Charles A Lacson
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Revery P Barnes
- Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hossein Bahrami
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Division of Cardiovascular Medicine, Department of Medicine, University of Southern California, Los Angeles, CA, USA. .,Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Division of Cardiology, Department of Medicine, Keck School of Medicine of University of Southern California, 2020 Zonal Ave, Los Angeles, CA, 90033, USA.
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LaFleur J, Bress AP, Rosenblatt L, Crook J, Sax PE, Myers J, Ritchings C. Cardiovascular outcomes among HIV-infected veterans receiving atazanavir. AIDS 2017; 31:2095-2106. [PMID: 28692532 PMCID: PMC5603981 DOI: 10.1097/qad.0000000000001594] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/27/2017] [Accepted: 06/27/2017] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Patients with HIV infection have an increased risk of cardiovascular disease compared with uninfected individuals. Antiretroviral therapy with atazanavir (ATV) delays progression of atherosclerosis markers; whether this reduces cardiovascular disease event risk compared with other antiretroviral regimens is currently unknown. DESIGN Population-based, noninterventional, historical cohort study conducted from 1 July 2003 through 31 December 2015. SETTING Veterans Health Administration hospitals and clinics throughout the United States. PARTICIPANTS Treatment-naive patients with HIV infection (N = 9500). ANTIRETROVIRAL EXPOSURES Initiating antiretroviral regimens containing ATV, other protease inhibitors, nonnucleoside reverse transcriptase inhibitors (NNRTIs), or integrase strand transfer inhibitors (INSTIs). MAIN OUTCOME/EFFECT SIZE MEASURES Incidence rates of myocardial infarction (MI), stroke, and all-cause mortality within each regimen. ATV versus other protease inhibitor, NNRTI, or INSTI covariate-adjusted hazard ratios by using Cox proportional hazards models and inverse probability of treatment weighting. RESULTS Incidence rates for MI, stroke, and all-cause mortality with ATV-containing regimens (5.2, 10.4, and 16.0 per 1000 patient-years, respectively) were lower than with regimens containing other protease inhibitors (10.2, 21.9, and 23.3 per 1000 patient-years), NNRTIs (7.5, 15.9, and 17.5 per 1000 patient-years), or INSTIs (13.0, 33.1, and 21.5 per 1000 patient-years). After inverse probability of treatment weighting, adjusted hazard ratios (95% confidence intervals) for MI, stroke, and all-cause mortality with ATV-containing regimens versus all non-ATV-containing regimens were 0.59 (0.41-0.84), 0.64 (0.50-0.81), and 0.90 (0.73-1.11), respectively. CONCLUSION Among treatment-naive HIV-infected patients in the Veterans Health Administration initiating ATV-containing regimens, risk of both MI and stroke were significantly lower than in those initiating regimens containing other protease inhibitors, NNRTIs, or INSTIs.
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Affiliation(s)
- Joanne LaFleur
- Department of Pharmacotherapy, University of Utah College of Pharmacy
- Informatics, Decision-Enhancement, and Surveillance (IDEAS) Center, Salt Lake City VA Health Care System
| | - Adam P. Bress
- Informatics, Decision-Enhancement, and Surveillance (IDEAS) Center, Salt Lake City VA Health Care System
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | | | - Jacob Crook
- Informatics, Decision-Enhancement, and Surveillance (IDEAS) Center, Salt Lake City VA Health Care System
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Paul E. Sax
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joel Myers
- Bristol-Myers Squibb, Lawrenceville, New Jersey
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Cardiovascular toxicity of abacavir: a clinical controversy in need of a pharmacological explanation. AIDS 2017; 31:1781-1795. [PMID: 28537935 DOI: 10.1097/qad.0000000000001547] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
: There is a long-lasting controversy surrounding an association between abacavir (ABC) and an increased risk of cardiovascular disease in HIV-positive patients. Although differing in their specifics, a number of published cohort studies and clinical trials support such an association, usually relating it to recent exposure to the drug, independently of traditional predisposing factors. However, other clinical trials have failed to reveal such a relation and have pointed to methodological differences to explain discrepancies. Significantly, the controversy has been fueled by the lack of a credible mechanism of action to justify the putative detrimental actions of ABC. There is a myriad of contradictory clinical indicators which are not clearly compatible with known profiles of either vascular physiopathology or pharmacological interference. However, basic research has recently hinted at altered homeostatic mechanisms, though this requires clinical validation. In particular, recurrent evidence - both clinical and experimental - relates ABC with vascular inflammation, a leading contributor to the atherosclerotic plaque and thrombosis. ABC's chemical structure is very close to that of endogenous purines (ATP, ADP and AMP), major paracrine signaling molecules capable of triggering prothrombotic and proinflammatory vascular programs. Other proposed mechanisms are a competitive inhibition of guanylyl cyclase in platelets and a subsequent decrease in cyclic guanosine monophosphate (cGMP). The present review aims to shed light on this complex subject by summarizing and critically evaluating all the available clinical data regarding a relationship between ABC and cardiovascular disease, and to put forward potential pharmacological explanations compatible with both the clinical scenario and experimental findings.
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50
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Brief Report: Progression of Atherosclerosis in HIV-Infected Individuals-Prospective Data From an Asian Cohort. J Acquir Immune Defic Syndr 2017; 75:198-202. [PMID: 28498145 DOI: 10.1097/qai.0000000000001358] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The magnitude and risk factors of progression of atherosclerosis in Asian HIV-infected individuals were unknown. This study aimed to evaluate: (1) the rate of progression of atherosclerosis in HIV-infected individuals, and (2) metabolic and inflammatory parameters that may predict atherosclerosis progression in HIV-infected individuals in an Asian cohort. SETTING A prospective, longitudinal study was performed among adults attending an HIV Metabolic clinic in Hong Kong. METHODS Carotid intima media thickness (cIMT) was measured at baseline and 24 months. Body composition, metabolic, and inflammatory biomarkers [including homeostasis model assessment of insulin resistance, LDL (low-density lipoprotein) cholesterol particle size, high-sensitive C reactive protein, adiponectin] associated with cIMT change were analyzed; their predictive performances were estimated using receiver operating characteristic analyses. RESULTS Sixty-one HIV-infected individuals (mean ± SD age 49.8 ± 11.4 years, 89% men, 97% Chinese, diabetes 39%, hypertension 30%, and dyslipidemia 85%) were recruited. Annual rate of change of cIMT was +0.0075 (0.0000-0.0163) mm/yr, and 19% developed new plaque at 24 months. Two patients died during the study period, 1 because of sudden cardiac death. Using receiver operating characteristic analyses, combination of lower limb fat percentage, LDL cholesterol subclass pattern B, and lower adiponectin level, but not Framingham score, predicted greater cIMT progression in HIV-infected individuals. CONCLUSIONS Asian HIV-infected individuals had atherosclerosis progression. Limb fat percentage, LDL cholesterol particle size, and adiponectin level may identify at-risk Asian HIV-infected individuals for early intervention.
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