HIV-related cardiovascular disease: closing the gap in mortality

Pulmonary Kaposi Sarcoma without Respiratory Symptoms and Skin Lesions in an HIV-Naïve Patient: A Case Report and Literature Review

Kaposi sarcoma (KS) is a multifocal lympho-angioproliferative, mesenchymal low-grade tumor associated with a γ2-herpesvirus, named Kaposi sarcoma-associated virus or human herpesvirus (KSHV/HHV8). The lung is considered a usual anatomical location of KS, despite being infrequent, often in association with extensive mucocutaneous lesions and very uncommonly as an isolated event. We report a case of a pulmonary KS (pKS) in a human immunodeficiency virus (HIV) naïve patient, which was atypical due to a lack of cutaneous involvement and an absence of respiratory symptoms. The pKS was initially identified as a tumoral suspected nodular lesion and only after immunohistochemical analysis was it characterized as KS. Furthermore, the diagnosis of pKS led to the discovery of the HIV-seropositive status of the patient, previously unknown. Our report underlines the importance of considering pKS even without skin lesions and as a first manifestation of HIV infection. We also reviewed literature on the current knowledge about pKS in people living with HIV (PLWH) to underline how one of the most common HIV/acquired immunodeficiency syndrome (AIDS) associated tumors can have a challenging localization and be difficult to recognize.

Contemporary trends in HIV-associated neurocognitive disorders in Ghana

BACKGROUND

Widespread introduction of early combination antiretroviral therapy (cART) for People Living with HIV (PLWH) will influence the burden, profile, and trajectory of HIV-associated neurocognitive disorders (HAND) in the 21st century.

OBJECTIVES

To assess the prevalence and trajectory of HAND among PLWH in a Ghanaian tertiary medical center.

METHODS

We analyzed the dataset of a study involving PLWH established on cART (n = 256) and PLWH not initially on cART (n = 244). HIV-negative individuals (n = 246) served as normative controls for neurocognitive assessments. HAND was defined according to the Frascati criteria into asymptomatic neurocognitive impairment (ANI), mild neurocognitive disorder (MND) and HIV-associated dementia (HAD) at enrollment and at month 12. Multivariate logistic regression models were fitted to identify factors associated with HAND.

RESULTS

Among PLWH on cART, 21.5%, 3.5% and 0.0% had ANI, MND and HAD respectively compared with 20.1%, 9.8% and 2.0% among PLWH cART naïve, p < 0.0001. Overall, 71.6%, 20.8%, 6.6% and 1.0% had no cognitive impairment, ANI, MND and HAD at baseline. Among participants who completed month 12 follow-up, 55.2% had no cognitive impairment, 43.5%, 1.2%, 0.0% had ANI, MND and HAD respectively, p < 0.0001. Adjusted odds ratio (95% CI) of six independent predictors of HAND at month 12 were no education (3.29;1.81-6.00), stage 4 disease (4.64;1.37-15.69), hypertension (2.28;1.10-4.73), nevirapine use (2.05;1.04-4.05), baseline viral load (0.66;0.56-0.77), and cigarette use (0.10; 0.03-0.42).

CONCLUSION

Most Ghanaian patients in the post-cART era with HAND had mild neurocognitive impairments. The impact of hypertension on progression of HAND warrants further evaluation in our settings.

Role of Brain Arterial Remodeling in HIV-Associated Cerebrovascular Outcomes

As the life expectancy of people living with HIV (PLWH) on combination antiretroviral therapy (cART) increases, so does morbidity from cerebrovascular disease and neurocognitive disorders. Brain arterial remodeling stands out as a novel investigational target to understand the role of HIV in cerebrovascular and neurocognitive outcomes. We therefore conducted a review of publications in PubMed, EMBASE, Web of Science and Wiley Online Library, from inception to April 2021. We included search terms such as HIV, cART, brain, neuroimmunity, arterial remodeling, cerebrovascular disease, and neurocognitive disorders. The literature shows that, in the post-cART era, PLWH continue to experience an increased risk of stroke and neurocognitive disorders (albeit milder forms) compared to uninfected populations. PLWH who are immunosuppressed have a higher proportion of hemorrhagic strokes and strokes caused by opportunistic infection and HIV vasculopathy, while PLWH on long-term cART have higher rates of ischemic strokes, compared to HIV-seronegative controls. Brain large artery atherosclerosis in PLWH is associated with lower CD4 nadir and higher CD4 count during the stroke event. HIV vasculopathy, a form of non-atherosclerotic outward remodeling, on the other hand, is associated with protracted immunosuppression. HIV vasculopathy was also linked to a thinner media layer and increased adventitial macrophages, suggestive of non-atherosclerotic degeneration of the brain arterial wall in the setting of chronic central nervous system inflammation. Cerebrovascular architecture seems to be differentially affected by HIV infection in successfully treated versus immunosuppressed PLWH. Brain large artery atherosclerosis is prevalent even with long-term immune reconstitution post-cART. HIV-associated changes in brain arterial walls may also relate to higher rates of HIV-associated neurocognitive disorders, although milder forms are more prevalent in the post-cART era. The underlying mechanisms of HIV-associated pathological arterial remodeling remain poorly understood, but a role has been proposed for chronic HIV-associated inflammation with increased burden on the vasculature. Neuroimaging may come to play a role in assessing brain arterial remodeling and stratifying cerebrovascular risk, but the data remains inconclusive. An improved understanding of the different phenotypes of brain arterial remodeling associated with HIV may reveal opportunities to reduce rates of cerebrovascular disease in the aging population of PLWH on cART.

Managing HIV-associated inflammation and ageing in the era of modern ART

OBJECTIVES

This paper aims to address the concerns around ongoing immune activation, inflammation, and resistance in those ageing with HIV that represent current challenges for clinicians.

METHODS

Presentations at a symposium addressing issues of ageing with HIV infection were reviewed and synthesised.

RESULTS

The changing natural history and demographics of human immunodeficiency virus (HIV)-infected individuals means new challenges in contemporary management. In the early years of the epidemic,management was focussed on acute, potentially life-threatening AIDS-related complications. From initial monotherapy with first-generation antiretroviral therapy (ART), the development of combination highly active ART (HAART) allowed HIV control but ART toxicities, treatment adherence and drug resistance emerged as major issues. Today, the availability of potent and tolerable ART has made viral suppression achievable in most people living with HIV (PLHIV), and clinicians are confronted with managing a chronic condition among an ageing population. The combination of diseases of ageing and the co-morbidities associated with HIV-infection, even when well controlled, results in a complex set of challenges for many older PLHIV. There is a growing appreciation that many non-AIDS-related co-morbidities are caused, at least in part, by persistent, low-grade immune activation, inflammation, and hypercoagulability, despite suppressive ART.

CONCLUSIONS

In order to further improve HIV management, it is important to understand the enduring effects of chronically suppressed HIV infection, the potential contribution of these factors to the ageing process, the possibility of drug resistance, and the impact of different treatment strategies, including early ART initiation.

The association of HIV and cocaine use to cigarette smoking in the context of depression and perceived stress

Mental well-being can contribute to cigarette smoking and negatively impact disease progression among people living with HIV (PLWH). This study examined potential associations between cocaine use (COC), depression, and HIV status in predicting cigarette smoking; hypothesizing that depression would be highest in cocaine users and predict cigarette smoking. An exploratory analysis including stress was also examined as a potential predictor of cigarette use. More than half of the sample (65%) endorsed smoking at some point in the past, and 52% endorsed being current smokers at the time of the study. Smokers were most likely to be cocaine users (87.1%), cocaine using PLWH (74.3%), or PLWH (36.6%). Neither HIV status (χ2(1) = 1.5, p = .221), perceived stress (χ2(1) = 0.75 p = .386), nor depressive symptomatology (χ2(1) = 1.2, p = .274) were related to smoking. Non-cocaine users were approximately 95.4% less likely to smoke than cocaine users, controlling for all other variables. Overall, cocaine use was the greatest predictor of cigarette smoking and quantity of cigarettes smoked. Perceived stress and depression were not associated with cigarette smoking in the sample. Future interventions targeting cigarette use should include a cocaine-related component to encourage smoking cessation among this high-risk group.

The contribution of syndemic conditions to cardiovascular disease risk

The syndemic conditions of low education, childhood maltreatment, depression, HIV, alcohol and cocaine use, and obesity have been established as independent risk factors for cardiovascular risk, but research examining the association between syndemic conditions and cardiovascular risk in high-risk populations is lacking. A total of N = 503 participants underwent an ultrasound of the carotid artery to assess for atherosclerotic plaque. Participants, HIV-infected (n = 202) and HIV-uninfected (n = 301) with and without a history of cocaine use, were a mean age of 36.13 years (SD = 9.51); 50% were male, and 62% were African-American. Each syndemic condition was associated with 8% greater odds of atherosclerotic plaque (OR = 1.08), 9% greater odds of systolic blood pressure (OR = 1.09), and 10% greater odds of diastolic blood pressure (OR = 1.10). Multilevel research, interventions, and public policy initiatives are needed to activate stakeholders at each level to maximize their impact at a community level among populations with high rates of syndemic conditions.

Cardiovascular risk factors in HIV infected individuals: Comparison with general adult control population in Greece

Background

Although combined antiretroviral therapy has substantially improved the prognosis of people living with HIV (PLHIV), mortality remains higher compared to the general population, mainly due to higher prevalence of non-HIV-related comorbidities, including cardiovascular diseases (CVD). We assessed the prevalence of CVD risk and its contributing factors in adult PLHIV versus general population controls in Greece.

Settings

Cross-sectional comparison of PLHIV (Athens-Multicenter-AIDS-Cohort-Study; AMACS) versus general population controls (National health examination survey; EMENO).

Methods

All HIV-infected adults with ≥1 measurement of interest (blood pressure, lipids, glucose, weight, height) between 2012–2014 and all EMENO participants (2014–2016) were included. Ten-year total CVD risk was estimated using the Framingham (FRS) or the Systematic Coronary Risk Evaluation (SCORE) equations.

Results

5839 PLHIV (median age:41.6 years, 85.4% males) and 4820 controls (median age:48 years, 48.4% males) were included. Adjusting for age, sex and origin, PLHIV were more likely to be current smokers (adjusted OR:1.53 [95% CI:1.35–1.74]) and dyslipidemic (aOR:1.18; [1.04–1.34]), less likely to be obese (aOR:0.44 [0.38–0.52], with no differences in hypertension, diabetes or high (≥20%) FRS but with greater odds of high (≥5%) SCORE (aOR:1.55 [1.05–2.30]). Further adjustment for educational level, anti-HCV positivity and BMI showed higher prevalence of hypertension in PLHIV.

Conclusions

Despite the relative absence of obesity, PLHIV have higher prevalence of traditional CVD risk factors and higher risk of fatal CVD compared to general population. Regular screening and early management of CVD risk factors in PLHIV should be of high priority for CVD prevention.

Assessing inflammation and its role in comorbidities among persons living with HIV

PURPOSE OF REVIEW

This article describes the use of biomarkers in expanding our understanding of chronic non-AIDS comorbidities among persons living with HIV (PLWH) receiving antiretroviral therapy (ART).

RECENT FINDINGS

We review current evidence that biomarkers of chronic immune activation and inflammation associate with a broad spectrum of end-organ diseases in PLWH. We discuss how ART may impact inflammation associated with HIV infection and the degree to which inflammation persists despite effective suppression of viral replication in plasma. We then discuss the limitations of the current literature, which lacks evidence of causality and disproportionately involves a few protein biomarkers that are unable to disentangle complex and overlapping biological pathways.

SUMMARY

Premature end-organ disease among PLWH has been repeatedly associated with higher levels of blood biomarkers reflecting inflammation and immune activation, which, despite viral suppression and CD4 T-cell increases after ART treatment, remain elevated relative to uninfected persons. There remain important unanswered questions with implications for the development of anti-inflammatory treatment strategies aimed at mitigating excess risk for end-organ comorbidities among PLWH.

A global bibliometric analysis of antiretroviral treatment adherence: implications for interventions and research development (GAPRESEARCH)

The introduction of antiretroviral therapy (ART) has helped HIV population to live longer, but they could face not only AIDS-related morbidity but also other non-communicable diseases. Paying attention to ART adherence requires a system thinking with the life-long factors, individual-environment interactions and contextualized dynamics. Although several quantitative research had been conducted, they were not able to fully demonstrate the development of research approaches and scopes of previous studies. Essential and practical public health policy should be based on the most accessible and strategically analyzed evidence. Therefore, our study uses a scientometric approach to supplement previous reviews research covering until the end of 2017. Using a combination of two quantitative approaches to supplement previous reviews, we attempt to identify the research trends and potential research gaps which could be very helpful for policies and practices enhancements to inform evidence-based strategies. Our result indicates countries tend to collaborate in traditional models rather than prioritize severity and characteristics of HIV epidemics. Further ART research should highlight the incorporation of newly developed technology to examine long-term impacts, combine multiple measures, address contextual factors, and involve available technologies and resources, e.g., family, community.

Role of Noncommunicable Diseases (NCDs) in Resource-Limited Settings (RLS)

PURPOSE OF REVIEW

As access to effective antiretroviral therapy (ART) expands globally, a decline in AIDS-related morbidity and mortality has been complicated by rising rates of noncommunicable diseases (NCDs). This review provides a brief description of NCDs and existing gaps on knowledge about NCDs among HIV-infected adults mostly in Africa.

RECENT FINDINGS

Recent reports show that one in every five persons living with HIV has a chronic illness, predominantly diabetes and/or hypertension, depression, and most of these conditions are either not diagnosed or not being managed. Human papilloma virus-associated anal dysplasia occurs among 70% of HIV-infected women in RLS. Recognizing risk factors for NCDs and providing effective screening and optimal care remains challenging. Research is urgently needed to carefully characterize HIV-associated NCDs in RLS. Such studies should provide a framework for high-priority NCDs that the limited resources can be focused on in these settings.

Cardiac morbidity in HIV infection is associated with checkpoint inhibitor LAG-3 on CD4 T cells

Recent findings point to a role of Checkpoint Inhibitor (CPI) receptors at the tissue level in immune homeostasis. Here we investigated the role of CPI molecules on immune cells in relation to cardiac function. Participants recruited in Chennai, India consisted of HIV+ ART naive viremic (Gp1 n = 102), HIV+ on ART, virologically suppressed (Gp2, n = 172) and HIV negative healthy controls (Gp3, n = 64). A cross-sectional analysis of cardiac function, arterial resistance and immunologic assessment of CPI expressing T cells was performed. Data indicate that ART naive exhibited cardiac function impairment and greater arterial stiffness than the other groups. Frequencies of CD4+ T cells expressing LAG-3 and PD1 were higher in ART naïve while TIGIT and TIM3 were similar among the patient groups. LAG-3+, PD1+ and dual LAG-3+PD1+ CD4 T cells were inversely correlated with cardiac function and arterial elasticity and directly with arterial stiffness in ART naïve participants and with arterial elasticity in virally suppressed group on ART. We conclude that HIV induced upregulation of LAG-3 singly or in combination with PD1 in immune cells may regulate cardiac health and warrant mechanistic investigations. The implications of these findings have bearing for the potential utility of anti-LAG-3 immunotherapy for cardiac dysfunction in chronic HIV infection.