Carotid Intima-Media Thickness and Arterial Stiffness in HIV-Infected Patients: The Role of HIV, Antiretroviral Therapy, and Lipodystrophy

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Associative Prediction of Carotid Artery Plaques Based on Ultrasound Strain Imaging and Cardiovascular Risk Factors in People Living With HIV and Age-Matched Control Subjects of the CHACS Cohort

BACKGROUND

There is a need for a specific atherosclerotic risk assessment for people living with HIV (PLWH).

SETTING

A machine learning classification model was applied to PLWH and control subjects with low-to-intermediate cardiovascular risks to identify associative predictors of diagnosed carotid artery plaques. Associations with plaques were made using strain elastography in normal sections of the common carotid artery and traditional cardiovascular risk factors.

METHODS

One hundred two PLWH and 84 control subjects were recruited from the prospective Canadian HIV and Aging Cohort Study (57 ± 8 years; 159 men). Plaque presence was based on clinical ultrasound scans of left and right common carotid arteries and internal carotid arteries. A classification task for identifying subjects with plaque was defined using random forest (RF) and logistic regression models. Areas under the receiver operating characteristic curves (AUC-ROCs) were applied to select 5 among 50 combinations of 4 or less features yielding the highest AUC-ROCs.

RESULTS

To retrospectively classify individuals with and without plaques, the 5 most discriminant combinations of features had AUC-ROCs between 0.76 and 0.79. AUC-ROCs from RF were statistically significantly higher than those obtained with logistic regressions ( P = 0.0001). The most discriminant features of RF classifications in PLWH were age, smoking status, maximum axial strain and pulse pressure (equal weights), and sex and antiretroviral therapy exposure (equal weights). When considering the whole population, the HIV status was identified as a cofactor associated with carotid artery plaques.

CONCLUSIONS

Strain elastography adds to traditional cardiovascular risk factors for identifying individuals with carotid artery plaques.

Immune correlates of cardiovascular co-morbidity in HIV infected participants from South India

BACKGROUND

Understanding the immune correlates of cardiovascular disease (CVD) risk in HIV infection is an important area of investigation in the current era of aging with HIV infection. Less is known about CVD risk and HIV infection in developing nations where additional risk factors may be playing a role in the CVD development. In this study, we assessed the effects of systemic inflammation, microbial translocation (MT), T cell immune activation (IA), and nadir CD4 counts on cardiac function and arterial stiffness as markers of subclinical atherosclerosis in HIV-infected individuals.

METHODS

People with HIV (PWH) who were ART naïve (n = 102) or virally suppressed on ART (n = 172) were stratified on nadir CD4 counts and compared to HIV-uninfected controls (n = 64). Determination was made of cardiac function via radial pulse wave and carotid intima thickness (C-IMT) measurements. Plasma biomarkers of inflammation and MT by ELISA or multiplex assays, and immune activation (IA) of T cells based HLA-DR and CD38 expression were investigated by flow cytometry. T-test, Mann-Whitney U test, and Spearman correlation were used to analyze study parameters.

RESULTS

Reduction in cardiac function with lower cardiac ejection time (p < 0.001), stroke volume (p < 0.001), cardiac output (p = 0.007), higher arterial stiffness (p < 0.05) were identified in ART-naïve participants, compared to PWH on ART (p < 0.05). No significant difference in C-IMT values were noted. Higher inflammatory and MT markers were found in the ART-naïve group compared to treated group who were comparable to uninfected participants, except for having higher TNF-α (p < 0.001) and sCD14 (p < 0.001). Immune activation of CD4 and CD8 T-cells was greater in ART-naïve participants compared to ART-treated and uninfected controls (p < 0.05). Lower nadir CD4 counts, higher inflammation, and higher MT predicted poor cardiac measures in the ART-naïve with nadir CD4 < 200cells/mm³ manifesting the highest arterial stiffness, and lowest cardiac function, whereas ART-treated, even with nadir < 200 cells/mm³ were similar to uninfected in these measures.

CONCLUSIONS

In HIV-infected individuals, initiation of ART even at nadir of < 200 cells/mm³ may prevent or reverse cardiovascular disease outcomes that are easily measurable in low income countries.

Sexual orientation, gender identity, and gender expression: From current state to solutions for the support of lesbian, gay, bisexual, transgender, and queer/questioning patients and colleagues

Many of the systemic practices in medicine that have alienated lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals persist today, undermining the optimal care for these patients and isolating LGBTQ medical providers from their colleagues. The 2020 Task Force on Diversity, Equity, and Inclusion Report recently published by the Society for Vascular Surgery marked the first publication advocating for the inclusion of sexual orientation and sexual identity in the development of initiatives promoting and protecting diversity across vascular surgery. Vascular providers should be aware that it is crucial to cultivate an environment that is inclusive for LGBTQ patients because a large proportion of these patients have reported not self-disclosing their status to medical providers, either out of concern over potential personal repercussions or failing to recognize the potential relevance of LGBTQ status to their medical care. Safe Zone training has provided a standard resource for providers and staff that can be integrated into onboarding and routine training. Clarifying the current terminology for sexual orientation and identity will ensure that vascular providers will recognize patients who could benefit from screening for additional vascular risk factors relevant to this population related to sexual health, social behavior, physical health, and medical therapies. The adoption of gender neutral language on intake forms and general correspondence with colleagues is key to reducing the unintended exclusion of those with LGBTQ identities in both inpatient and outpatient environments. In many locales across the United States, the professional and personal repercussions for openly reporting LGBTQ status persist, complicating efforts toward quantifying, recognizing, and supporting these patients, practitioners, and trainees. Contributing to an inclusive environment for patients and peers and acting as a professional ally are congruent with the ethos in vascular surgery to treat all patients and colleagues with respect and optimize the healthcare of every vascular patient.

Association of HIV Infection and Antiretroviral Therapy With Arterial Stiffness: A Systematic Review and Meta-Analysis

[Figure: see text].

Serum vitamin E deficiency among people living with HIV and undergoing antiretroviral therapy at Ho Teaching Hospital, Ghana

Vitamin E is a potent antioxidant that helps to counteract oxidative stress in the body. Oxidative stress is known to greatly affect people living with HIV (PLWH) through the stimulation of HIV replication and apoptosis of CD4+ T cells. There is however, a paucity of scientific data on the serum levels of vitamin E among PLWH in Ghana, and hence, there is a need to assess its level because of the pivotal role it plays in cell longevity determination and the immune system enhancement of such persons. This study aims to assess the serum levels of vitamin E among PLWH undergoing highly active antiretroviral therapy at Ho Teaching Hospital, Ghana. In a cross-sectional study, serum vitamin E levels of 103 randomly selected PLWH aged 24-88 years who attended an antiretroviral therapy clinic at the Ho Teaching Hospital, Ghana, were measured by following standard protocols. A 24-hour dietary recall and food frequency questionnaire were employed to assess dietary intake. The results show that a high level of serum vitamin E deficiency (82.5%) was observed among the participants. Majority (91.3%) of the participants had normal serum zinc status. Participants' serum vitamin E levels did not show significant correlation with their dietary intakes (correlation coefficient (ρ) = -0.094, p-value = 0.35). The prevalence of vitamin E deficiency among underweight, normal weight, overweight, and obese participants was 91.7%, 75.4%, 86.5%, and 91.7% respectively with no significant difference among these groups. There was no significant correlation between serum vitamin E levels and HIV infection duration (ρ = 0.010, p-value = 0.405) and HAART duration (ρ = 0.001, p-value = 0.313). The low serum vitamin E levels found in this study suggests that the participants could potentially be at an increased risk of developing oxidative stress and its effects.

Arterial structure and function in Africans with HIV for > 5 years: longitudinal relationship with endothelial activation and cardiovascular risk markers

OBJECTIVES

We aimed to determine whether people with human immunodeficiency virus (PWHIV) have increased measures of arterial injury [carotid intima-media thickness (cIMT)] and large artery stiffness [carotid-femoral pulse wave velocity (cfPWV)] when compared with their counterparts without HIV, and whether baseline markers of endothelial activation and cardiovascular risk are associated with cIMT and cfPWV after 5 years.

METHODS

We matched 126 PWHIV from North West Province, South Africa, to 126 without HIV according to age, sex and locality. Cardiovascular risk and endothelial function markers [soluble intracellular adhesion molecule (ICAM-1) and soluble vascular cell adhesion molecule (VCAM-1)] were measured at baseline and cIMT and cfPWV at follow-up.

RESULTS

This study included 21.4% men. The use of antiretroviral therapy (ART) increased from 44.1% at baseline to 81.4% at follow-up. At follow-up, cIMT (P = 0.90) and cfPWV (P = 0.35) were similar in the groups. Despite elevated ICAM-1 and VCAM-1 in the PWHIV (all P < 0.001) at baseline, these markers did not associate with cIMT and cfPWV after 5 years. In multivariable-adjusted regression analysis, cIMT associated positively with age (β = 0.31, P = 0.002) and triglyceride: high-density lipoprotein-cholesterol (β = 0.23, P = 0.016) in PWHIV. Mean arterial pressure (MAP) (β = 0.28, P = 0.010) associated positively with cfPWV in the PWHIV. In the people without HIV, sex (β = 0.31, P = 0.004) and glycated haemoglobin (HbA1c) (β = 0.24, P = 0.026) associated with cIMT while age (β = 0.17, P = 0.049), sex (β = 0.29, P = 0.003), MAP (β = 0.31, P = 0.001) and HbA1c (β = 0.21, P = 0.041) associated positively with cfPWV.

CONCLUSIONS

Measures of arterial structure and function were similar in Africans with HIV and their age, sex and locality matched controls. Traditional cardiovascular risk markers rather than elevated endothelial activation at baseline were independently associated with cIMT and cfPWV over 5 years.

Cardiovascular Disease Burden in Rural Africa: Does HIV and Antiretroviral Treatment Play a Role?: Baseline Analysis of the Ndlovu Cohort Study

Background

HIV is associated with an increased risk of cardiovascular disease (CVD) in high‐income countries. Little is known about the CVD burden in sub‐Saharan Africa, where 70% of the world's HIV‐positive population lives. This study aims to provide insight into the burden of CVD risk in a rural setting in sub‐Saharan Africa considering HIV infection and antiretroviral therapy (ART).

Methods and Results

A cross‐sectional analysis was conducted of the baseline of the Ndlovu Cohort study including HIV‐negative and HIV‐positive participants in rural South Africa between 2014 and 2017. Information was collected on demographics, socioeconomic status, and CVD risk factors. Carotid intima‐media thickness measurement was performed. The influence of HIV and ART on the burden of CVD was determined by comparing HIV‐positive participants who were ART naive on first‐line or second‐line ART with HIV‐negative participants. In total, 1927 participants were included, of whom 887 (46%) were HIV positive and 54% women. The median age was 38 years. Overall, 690 participants (79%) were on ART, with 613 (89%) on first‐line and 77 (11%) on second‐line therapy. Participants with HIV had lower values for most of the CVD risk factors but higher C‐reactive protein levels than HIV‐negative participants. ART‐naive, HIV‐positive participants had similar carotid intima‐media thickness compared with HIV‐negative participants but carotid intima‐media thickness was increased for participants on ART aged 30 years and older compared with HIV‐negative participants.

Conclusions

HIV‐positive participants presented with a favorable CVD risk profile compared with HIV‐negative participants. However, carotid intima‐media thickness was increased in HIV‐positive participants on ART, indicating a higher burden of subclinical CVD for the HIV‐positive population.

Electrocardiographic abnormalities among people with HIV in Shanghai, China

People living with HIV (PLWH) have an excess risk of cardiovascular diseases (CVD). Electrocardiographic (ECG) abnormalities are independently predictive of incident cardiovascular events in the general population. Our study aimed to evaluate the prevalence and correlates of ECG abnormalities among PLWH in Shanghai, China. We used a cross-sectional design to collect data from Shanghai Public Health Clinical Center, China. A total of 587 HIV-infected patients aged between 18 and 75 years were recruited between January 2015 and February 2016. The overall prevalence of any type of ECG abnormalities was 53.3%. The prevalence of sinus tachycardia, ST-T segment elevation and left ventricular hypertrophy was 23.0%, 18.1%, and 6.8%, respectively. Multivariable logistic regression analysis indicated that ST-T segment elevation was positively associated with higher baseline HIV viral load (≥ 4 log₁₀ copies/mL), and sinus tachycardia was negatively associated with older age but positively associated with lower CD4 cell count, higher baseline HIV viral load (≥ 4 log₁₀ copies/mL) and higher lactic dehydrogenase (LDH) level (≥133 mg/dL). Any coded ECG abnormality was positively associated with higher baseline HIV viral load (≥ 4 log₁₀ copies/mL). ECG abnormalities including sinus tachycardia and ST-T segment elevation are prevalent among Chinese HIV patients, which are significantly associated with immunodeficiency and HIV viral load. Routine ECG screening may be an important part of HIV clinical care in China.

Cardiovascular disease risk in an urban African population: a cross-sectional analysis on the role of HIV and antiretroviral treatment

BACKGROUND

Life expectancy is increasing in the HIV-positive population and age-related non-communicable diseases, such as cardiovascular disease, (CVD) are seen more frequently. This study investigated to what extent HIV and antiretroviral therapy (ART) is associated with CVD risk in an urban African population.

METHODS

A cross-sectional study was performed in Johannesburg, South Africa, between July 2016 and November 2017. Both HIV-positive adults (ART-naïve, or on first- or second-line ART), as well as age and sex matched HIV-negative controls who were family or friends of the HIV-positive participants were included. Data were collected on demographics, cardiovascular risk factors, HIV-related characteristics, carotid intima-media thickness (CIMT) and carotid distensibility. The association between HIV, ART and CIMT and distensibility was analysed with linear regression models, adjusting for age, gender and CVD risk factors.

RESULTS

The study included 548 participants, 337 (62%) females, age 38.3 ± 9.5 years of whom 104 (19.0%) were HIV-positive, ART-naïve; 94 (17.2%) were on first-line ART; 197 (35.9%) were on second-line ART; and 153 (27.9%) were HIV-negative. Participants on second-line ART had higher CIMT and lower distensibility compared to the other groups (p < 0.001). After adjustment for age, these outcomes were similar between groups. Further adjustment for CVD and HIV-related factors did not alter the findings.

CONCLUSION

Neither HIV nor ART was associated with CIMT or carotid distensibility in this urban African population. Longitudinal studies are needed to fully understand the relationship between HIV and CVD across different populations.

Prevalence and related drug cost of comorbidities in HIV-infected patients receiving highly active antiretroviral therapy in Taiwan: A cross-sectional study

BACKGROUND

To determine the prevalence of chronic comorbidities and associated medication costs in Taiwanese HIV patients in order to increase awareness of the disease burden among healthcare providers and patients.

METHODS

HIV-diagnosed patients receiving highly active antiretroviral therapy (HAART; 2010-2013) were identified from the Taiwan National Health Insurance Research Database with the corresponding International Classification of Diseases, ninth revision (ICD-9) code. Comorbidities (type II diabetes mellitus, hypertension, dyslipidemia, major depressive disorder, acute coronary syndrome, and cholelithiasis/nephrolithiasis) were identified according to ICD-9 or relevant medication use. Comorbidity medication and associated costs were identified using the drug classification code from the Anatomical Therapeutic Chemical classification system code series and series outpatient prescriptions.

RESULTS

Of 20,726 HIV-diagnosed Taiwanese patients (2010-2013), 13,142 receiving HAART were analyzed. Prevalence of all chronic comorbidities was significantly greater (p < 0.0001) in patients aged ≥40 years versus <40 years (diabetes mellitus, 14.95% vs. 3.30%; hypertension, 46.73% vs. 26.83%; dyslipidemia, 34.93% vs. 18.37%; depression, 23.75% vs. 19.88%; acute coronary syndrome, 1.16% vs. 0.21%; nephrolithiasis/cholelithiasis, 7.26% vs. 4.56%; >2 comorbidities, 24.80% vs. 7.21%). An increase in comorbidity medication spending (2010 vs. 2013 medication costs) was observed (antidyslipidemia, $88,878 vs. $168,180; antihyperglycemia, $32,372 vs. $73,518; antidepressants, $78,220 vs. $125,971; sedatives, $60,009 vs. $85,055; antihypertension, $47,115 vs. $95,134), contributing to overall treatment costs increasing almost two-fold from 2010 to 2013.

CONCLUSIONS

Among HIV-infected Taiwanese patients receiving HAART, significant increases in comorbidity prevalence with age, along with rising comorbidity medication costs, suggest the need for preventative as well as chronic care.

Abdominal Fat Depots and Subclinical Carotid Artery Atherosclerosis in Women With and Without HIV Infection

BACKGROUND

Data on associations between abdominal fat depot mass and subclinical atherosclerosis are limited, especially in women with HIV.

METHODS

We assessed cross-sectional associations of dual X-ray absorptiometry scan-derived estimates of visceral adipose tissue (VAT) and abdominal subcutaneous adipose tissue (SAT) with 3 measures of subclinical carotid artery atherosclerosis-carotid artery stiffness (Young's modulus of elasticity), presence of carotid artery lesions, and carotid artery intima-media thickness-in a subsample of participants in the Women's Interagency HIV Study. Statistical models adjusted for demographic variables, HIV serostatus, behavioral variables, and cardiovascular risk factors.

RESULTS

There were 244 women with and 99 without HIV infection (median age 42, 62% black). VAT mass (but not SAT) was associated with greater carotid artery stiffness in a fully adjusted linear regression model, including adjustment for SAT (β = 11.3 log 10·N·m per kg VAT, 95% confidence interval: 1.0 to 21.7). Greater SAT mass was associated with lower odds of having a carotid artery lesion in a fully adjusted model, including adjustment for VAT [adjusted odds ratio, 0.49 per kg of SAT (0.25 to 0.94)]. Neither VAT nor SAT was associated with carotid artery intima-media thickness. The VAT/SAT ratio was not statistically associated with any of the outcomes after covariate adjustment.

CONCLUSIONS

In our cross-sectional study of women, the majority of whom had HIV, greater VAT mass was associated with increased carotid artery stiffness, whereas greater SAT mass was associated with a reduced odds of prevalent carotid artery lesions.

Triad of the Ischemic Cardiovascular Disease in People Living with HIV? Association Between Risk Factors, HIV Infection, and Use of Antiretroviral Therapy

PURPOSE OF REVIEW

This review is focused on cardiovascular risk factors in HIV-infected people.

RECENT FINDINGS

Antiretroviral therapy (ART) has significantly increased the life expectancy of HIV-infected people. Thus, this population has experienced non-HIV-related diseases, mainly cardiovascular diseases. Thus, in our review, we intend to understand the cardiovascular risk factors that trigger this situation. We have demonstrated that both ART and traditional cardiovascular risk factors contribute to the development of cardiovascular disease in HIV-infected people. Thus, it becomes important to stratify the risk factors to reduce this scenario.

Visceral adipose tissue and carotid intima-media thickness in HIV-infected patients undergoing cART: a prospective cohort study

BACKGROUND

Combined antiretroviral therapy (cART) in HIV-infected patients has been associated with lipodystrophy, metabolic abnormalities, and an increased risk of cardiovascular disease. Ultrasound measures of carotid artery intima-media thickness (cIMT) have been used as a valid measure of subclinical atherosclerosis and as a tool to predict the risk of cardiovascular events. Our aim was to evaluate the progression of cIMT in HIV-infected patients subjected to cART, with and without lipodystrophy, over a one-year period.

METHODS

We performed a one-year prospective cohort study to compare changes in cIMT, metabolic and inflammation markers in HIV-infected patients undergoing cART. Body composition was assessed by dual-energy X-ray absorptiometry (DXA) and abdominal computed tomography (CT). Levels of blood pressure, lipids and inflammatory markers were evaluated, as well as ultrasound measures of cIMT. Lipodystrophy defined by Fat Mass Ratio (L-FMR) is measured as the ratio of the percentage of trunk fat mass to the percentage of lower limb fat mass by DXA. Categorical variables were compared, using the chi-square or Fisher's exact test. Wilcoxon ranks tests and the McNemar chi-square tests were used to compare results of selected variables, from the first to the second year of evaluation. Means of cIMT, adjusted for age, glucose, triglycerides levels, systolic blood pressure (SBP), and waist to hip ratio were calculated, using generalised linear models for repeated measures.

RESULTS

L-FMR was present in 44.3% of patients, and the mean of cIMT increased significantly in this group [0.82 (0.26) vs 0.92 (0.33); p = 0.037], as well as in patients without lipodystrophy [0.73 (0.20) vs 0.84 (0.30); p = 0.012]. In the overall sample, the progression of cIMT was statistically significant after the adjustment for age, glucose, triglycerides, and SBP, but the significance of the progression ceased after the adjustment for waist/hip ratio [0.770 (0.737-0.803) vs 0.874 (0.815-0.933); p = 0.514].

CONCLUSIONS

Carotid IMT progressed significantly in both groups of this HIV-infected cohort, however no association between the progression of cIMT and the presence of lipodystrophy defined by FMR was found. Visceral adipose tissue had an impact on the increment of cIMT, both in patients with, and without lipodystrophy defined by FMR.

The impact of dark chocolate intake on arterial elasticity in individuals with HIV/AIDS undergoing ART: a randomized, double-blind, crossover trial

An increase in the frequency of cardiovascular diseases has been observed in the HIV/AIDS population. Studies involving healthy subjects or subjects with other diseases have shown benefits of chocolate supplementation on endothelial function and vasodilation. We evaluate the impact of chocolate consumption on arterial elasticity in people living with human immunodeficiency virus - PLHIV. A double-blind, crossover trial including 110 PLHIV (19 to 59 years) on antiretroviral therapy - ART for at least 6 months and with a viral load of <500 copies per mL was conducted. All subjects were randomly assigned to 15-d dietary supplements containing dark chocolate or placebo with a 15-d washout period. Each participant received one of the two sequences: A (dark chocolate, placebo chocolate); B (placebo chocolate, dark chocolate). Arterial elasticity was measured using the HDI/PulseWave™ CR-2000 CardioVascular Profiling System®. Body composition, lipid profile, C-reactive protein, and thiobarbituric acid reactive substances were also assessed. Analysis of variance (ANOVA) for repeated measures using the Stata 11.0® program was used for cross-over analysis. Most subjects were men (59.0%) and Caucasian (46.1%) and the mean age was 44.6 ± 7.1 years. The mean time since diagnosis of HIV infection was 13.7 ± 5.3 years and the mean duration of ART was 12.9 ± 4.2 years. Chocolate consumption resulted in significant alterations in the large artery elasticity index - LAEI (p = 0.049) and the mean concentration of HDL-c was higher after supplementation with dark chocolate (p = 0.045). This is the first study to evaluate the effect of chocolate on arterial elasticity in PLHIV. The results showed that dark chocolate consumption for 15 days improved the elastic properties of the LAEI in PLHIV. These findings, added to the noninvasive method used, may expand the knowledge of CVDs in this population.

Elevated Markers of Vascular Remodeling and Arterial Stiffness Are Associated With Neurocognitive Function in Older HIV+ Adults on Suppressive Antiretroviral Therapy

BACKGROUND

HIV is associated with elevated markers of vascular remodeling that may contribute to arterial fibrosis and stiffening and changes in pulse pressure (PP). These changes may, in turn, deleteriously affect autoregulation of cerebral blood flow and neurocognitive function.

METHODS

To evaluate these mechanisms, we studied markers of vascular remodeling, PP, and neurocognitive function among older (≥50 years of age) HIV-infected (HIV+, n = 72) and HIV-seronegative (HIV-, n = 36) adults. Participants completed standardized neurobehavioral and neuromedical assessments. Neurocognitive functioning was evaluated using a well-validated comprehensive battery. Three plasma biomarkers of vascular remodeling (ie, angiopoietin 2, Tie-2, and vascular endothelial growth factor, VEGF) were collected.

RESULTS

HIV+ and HIV- participants had similar levels of plasma angiopoietin 2 (P = 0.48), Tie-2 (P = 0.27), VEGF (P = 0.18), and PP (P = 0.98). In a multivariable regression model, HIV interacted with Tie-2 (β = 0.41, P < 0.01) and VEGF (β = -0.43, P = 0.01) on neurocognitive function, such that lower Tie-2 and higher VEGF values were associated with worse neurocognitive function for HIV+ participants. Greater Tie-2 values were associated with increased PP (r = 0.31, P < 0.01). In turn, PP demonstrated a quadratic association with neurocognitive function (β = -0.33, P = 0.01), such that lower and higher, relative to mean sample, PP values were associated with worse neurocognitive function.

CONCLUSIONS

These findings indicate that vascular remodeling and altered cerebral blood flow autoregulation contribute to neurocognitive function. Furthermore, HIV moderates the association between vascular remodeling and neurocognitive function but not the association between PP and neurocognitive function.

Difference in Aortic Stiffness Between Treated Middle-Aged HIV Type 1-Infected and Uninfected Individuals Largely Explained by Traditional Cardiovascular Risk Factors, With an Additional Contribution of Prior Advanced Immunodeficiency

BACKGROUND

Patients with HIV, even with suppressed viremia on combination antiretroviral therapy, are at increased risk for cardiovascular disease. The underlying pathophysiology remains to be clarified. Aortic stiffness, known to be associated with cardiovascular disease in the general population, was investigated in a cohort of HIV type 1 (HIV 1)-infected and similar but uninfected individuals.

METHODS

Aortic stiffness was assessed by measuring pulse wave velocity (PWV) with an Arteriograph. Five hundred seven HIV-uninfected and 566 HIV 1-infected individuals, predominantly with suppressed viremia on combination antiretroviral therapy, aged ≥45 years, participating in the ongoing AGEhIV Cohort Study were included in the analysis. Multivariable linear regression was used to investigate whether HIV was independently associated with aortic stiffness, adjusting for traditional cardiovascular risk factors.

RESULTS

Study groups were comparable in demographics; smoking and hypertension were more prevalent in HIV-infected participants. PWV was higher in the HIV-infected group (7.9 vs. 7.7 m/s, P = 0.004). After adjustment for mean arterial pressure, age, gender, and smoking, HIV status was not significantly associated with aortic stiffness. In HIV-infected participants, having a nadir CD4 T-cell count ≤100 cells per cubic millimeter was independently associated with a higher PWV.

CONCLUSIONS

The increased aortic stiffness in HIV-infected participants was largely explained by a higher prevalence of traditional cardiovascular risk factors, particularly smoking. Although HIV itself was not independently associated with higher aortic stiffness, a prior greater degree of immunodeficiency was. This suggests a detrimental effect of immunodeficiency on the aortic wall, possibly mediated by inflammation.

Oxidative Stress during HIV Infection: Mechanisms and Consequences

It is generally acknowledged that reactive oxygen species (ROS) play crucial roles in a variety of natural processes in cells. If increased to levels which cannot be neutralized by the defense mechanisms, they damage biological molecules, alter their functions, and also act as signaling molecules thus generating a spectrum of pathologies. In this review, we summarize current data on oxidative stress markers associated with human immunodeficiency virus type-1 (HIV-1) infection, analyze mechanisms by which this virus triggers massive ROS production, and describe the status of various defense mechanisms of the infected host cell. In addition, we have scrutinized scarce data on the effect of ROS on HIV-1 replication. Finally, we present current state of knowledge on the redox alterations as crucial factors of HIV-1 pathogenicity, such as neurotoxicity and dementia, exhaustion of CD4+/CD8+ T-cells, predisposition to lung infections, and certain side effects of the antiretroviral therapy, and compare them to the pathologies associated with the nitrosative stress.

Greater carotid intima media thickness at a younger age in HIV-infected patients compared with reference values for an uninfected cohort

OBJECTIVES

In contrast to the general population, no decline in cardiovascular disease (CVD) has been noted in HIV-infected patients over the last 10 years. We compared the carotid artery intima media thickness (CIMT) of HIV-infected patients to that of age- and gender-matched reference values and determined the relationship between CVD risk factors and CIMT.

METHODS

A total of 292 HIV-infected patients were enrolled in the study. Data collected included vascular screening data, data obtained using a questionnaire, data obtained from laboratory assessments and CIMT measurement. Using linear regression (adjusted for age/gender/known HIV), the association between HIV-specific and classical cardiovascular risk factors and CIMT was evaluated.

RESULTS

The cohort comprised for 91% of male patients, aged 49.4 ± 10.5 years, with a known duration of HIV infection of 8.8 ± 6.7 years. The mean with standard deviation (mean ± SD) CIMT was 0.77 ± 0.19 mm, compared with 0.58 ± 0.05 mm in the controls. A steeper increase of CIMT per age was seen in the HIV-infected patients. A significant relationship between CIMT and hypertension, diabetes mellitus, smoking, systolic blood pressure, HbA1c (glycated hemoglobin) and ankle brachial index was found. Of the HIV-specific variables, only a relationship between CIMT and length of cART use and between CIMT and (inversely) current cART use was seen.

CONCLUSIONS

A greater CIMT was found in HIV-infected patients compared with controls. In contrast to HIV-specific variables, classical CVD risk factors were associated with a greater CIMT and should therefore be the focus of preventive measures.

Human immunodeficiency virus-associated heart failure in sub-Saharan Africa: evolution in the epidemiology, pathophysiology, and clinical manifestations in the antiretroviral era

The survival of patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) who have access to highly active antiretroviral therapy (ART) has dramatically increased in recent times. This review focuses on HIV‐associated heart failure in sub‐Saharan Africa (SSA). In HIV infected persons, heart failure may be related to pathology of the pericardium, the myocardium, the valves, the conduction system, or the coronary and pulmonary vasculature. HIV‐associated heart failure can be because of direct consequences of HIV infection, autoimmune reactions, pro‐inflammatory cytokines, opportunistic infections (OIs) or neoplasms, use of ART or therapy for OIs and presence of traditional cardiovascular risk factors. Myocardial involvement includes diastolic dysfunction, asymptomatic left ventricular dysfunction, cardiomyopathy, myocarditis, fibrosis, and steatosis. Pericardial diseases include pericarditis, pericardial effusions (rarely causing tamponade), pericardial constriction, and effusive‐constrictive syndromes. Coronary artery disease is commonly reported in industrial nations, although its prevalence is thought to be low in HIV‐infected persons from SSA.

START or SMART? Timing of Antiretroviral Therapy Initiation and Cardiovascular Risk for People With Human Immunodeficiency Virus Infection

The Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection (START) study has reinforced the benefits of early initiation of antiretroviral therapy (ART). However, a notable secondary finding from that study was that immediate initiation of ART did not prevent cardiovascular disease (CVD) events (0.17 vs 0.20 events/1000 person-years, P = .65). This result appears to contradict a body of evidence, most notably from the Strategies for Management of Antiretroviral Therapy (SMART) study, which reported a 70% increased hazard of cardiovascular events for those deferring or interrupting treatment. Thus, an important unresolved question is whether the timing of ART impacts CVD risk. In this review, published data on relationships between timing of ART and CVD risk are reviewed. The data support a role for ART in mitigating CVD risk at lower CD4 counts, but data also suggests that, among those initiating therapy early, ART alone appears to suboptimally mitigate CVD risk. Additional interventions to address CVD risk among human immunodeficiency virus-infected populations are likely to be needed.

Carotid artery thickness is associated with chronic use of highly active antiretroviral therapy in patients infected with human immunodeficiency virus: A 3.0 Tesla magnetic resonance imaging study

OBJECTIVES

While patients with HIV infection have an elevated stroke risk, ultrasound studies of carotid artery wall thickness have reported variable results. We hypothesized that subjects with HIV infection on chronic highly active antiretroviral therapy (HAART) would have increased carotid artery wall thickness by magnetic resonance imaging (MRI).

METHODS

This cross-sectional study compared carotid artery wall thickness between 26 individuals infected with HIV on chronic HAART and 20 controls, without HIV infection but with similar cardiovascular risk factors, using 3.0-T noncontrast MRI. Inclusion criteria included male gender, age 35-55 years, and chronic HAART (≥ 3 years) among HIV-seropositive subjects; those with known cardiovascular disease or diabetes were excluded.

RESULTS

Between subjects with HIV infection and controls, there were no differences in mean (±SD) age (47.8 ± 5.0 vs. 47.8 ± 4.7 years, respectively; P = 0.19) or cardiovascular risk factors (P > 0.05 for each). Mean (±SD) wall thickness was increased in those with HIV infection vs. controls for the left (0.88 ± 0.08 vs. 0.83 ± 0.08 mm, respectively; P = 0.03) and right (0.90 ± 0.10 vs. 0.85 ± 0.07 mm, respectively; P = 0.046) common carotid arteries. Among individuals with HIV infection, variables associated with increased mean carotid artery wall thickness included lipoaccumulation [+0.09 mm; 95% confidence interval (CI) 0.03-0.14 mm; P = 0.003], Framingham risk score ≥ 5% (+0.07 mm; 95% CI 0.01-0.12; P = 0.02 mm), and increased duration of protease inhibitor therapy (+0.03 mm per 5 years; 95% CI 0.01-0.06 mm; P = 0.02).

CONCLUSIONS

Individuals with HIV infection on chronic HAART had increased carotid artery wall thickness as compared to similar controls. In subjects with HIV infection, the presence of lipoaccumulation and longer duration of protease inhibitor therapy were associated with greater wall thickness.

HIV, highly active antiretroviral therapy and the heart: a cellular to epidemiological review

The advent of potent highly active antiretroviral therapy (HAART) for persons infected with HIV-1 has led to a "new" chronic disease with complications including cardiovascular disease (CVD). CVD is a significant cause of morbidity and mortality in persons with HIV infection. In addition to traditional risk factors such as smoking, hypertension, insulin resistance and dyslipidaemia, infection with HIV is an independent risk factor for CVD. This review summarizes: (1) the vascular and nonvascular cardiac manifestations of HIV infection; (2) cardiometabolic effects of HAART; (3) atherosclerotic cardiovascular disease (ASCVD) risk assessment, prevention and treatment in persons with HIV-1 infection.

Is the atherosclerotic process accentuated under conditions of HIV infection, antiretroviral therapy, and protease inhibitor exposure? Meta-analysis of the markers of arterial structure and function

OBJECTIVE

To evaluate the apparent association of human immunodeficiency virus (HIV) infection, antiretroviral therapy (ART), and protease inhibitor (PI) exposure with the functional and structural markers of vasculature.

METHODS

A meta-analysis of the relationship between HIV infection, ART, and PI exposure and the functional and structural markers of vasculature. A systematic literature search was performed electronically using specific eligibility criteria. Weighted mean difference (WMD) and corresponding 95% confidence interval (CI) were calculated and combined appropriately.

RESULTS

Fifty-seven articles were included with nine different outcomes. Compared with HIV-negative patients, HIV-positive patients demonstrated significant elevated intima-media thickness (IMT) (WMD (95% CI) = 0.042 (0.028-0.057)), increased pulse wave velocity (PWV) (0.538 (0.283-0.792)), and reduced flow-mediated vasodilation (FMD) (-2.049 (-2.806 to -1.293)). Elevated IMT was observed in HIV patients receiving ART when compared with those naïve to ART in the 20- to 40-year-old age group (0.078 (0.033-0.123)), the >40-year-old age group (0.038 (0.018-0.057)), and the group comprising >50% males (0.070 (0.041-0.099)). In addition, ART resulted in an increased PWV in HIV patients receiving ART in the group with >50% male proportion (0.628 (0.405-0.851)). HIV patients exposed to PI showed a significant trend toward elevated IMT (0.033 (0.007-0.058)) and increased PWV (0.264 (0.118-0.410)) compared with those without PI exposure.

CONCLUSIONS

The atherosclerotic process was accentuated by elevated IMT, increased PWV, and reduced FMD under condition of HIV infection. Comparison of ART-receiving with ART-naïve patients showed a significant trend toward elevated IMT and increased PWV, especially under treatment with PI-containing drugs.

Current Efavirenz (EFV) or ritonavir-boosted lopinavir (LPV/r) use correlates with elevate markers of atherosclerosis in HIV-infected subjects in Addis Ababa, Ethiopia

BACKGROUND

HIV patients on antiretroviral therapy have shown elevated incidence of dyslipidemia, lipodystrophy, and cardiovascular disease (CVD). Most studies, however, focus on cohorts from developed countries, with less data available for these co-morbidities in Ethiopia and sub-Saharan Africa.

METHODS

Adult HIV-negative (n = 36), treatment naïve (n = 51), efavirenz (EFV)-treated (n = 91), nevirapine (NVP)-treated (n = 95), or ritonavir-boosted lopinavir (LPV/r)-treated (n=44) subjects were recruited from Black Lion Hospital in Addis Ababa, Ethiopia. Aortic pressure, augmentation pressure, and pulse wave velocity (PWV) were measured via applanation tonometry and carotid intima-media thickness (cIMT) and carotid arterial stiffness, and brachial artery flow-mediated dilation (FMD) were measured via non-invasive ultrasound. Body mass index, waist-to-hip circumference ratio (WHR), skinfold thickness, and self-reported fat redistribution were used to quantify lipodystrophy. CD4+ cell count, plasma HIV RNA levels, fasting glucose, total-, HDL-, and LDL-cholesterol, triglycerides, hsCRP, sVCAM-1, sICAM-1, leptin and complete blood count were measured.

RESULTS

PWV and normalized cIMT were elevate and FMD impaired in EFV- and LPV/r-treated subjects compared to NVP-treated subjects; normalized cIMT was also elevated and FMD impaired in the EFV- and LPV/r-treated subjects compared to treatment-naïve subjects. cIMT was not statistically different across groups. Treated subjects exhibited elevated markers of dyslipidemia, inflammation, and lipodystrophy. PWV was associated with age, current EFV and LPV/r used, heart rate, blood pressure, triglycerides, LDL, and hsCRP, FMD with age, HIV duration, WHR, and glucose, and cIMT with age, current EFV use, skinfold thickness, and blood pressure.

CONCLUSIONS

Current EFV- or LPV/r-treatment, but not NVP-treatment, correlated with elevated markers of atherosclerosis, which may involve mechanisms distinct from traditional risk factors.

Endothelial activation and cardiometabolic profiles of treated and never-treated HIV infected Africans

OBJECTIVE

The role the human immunodeficiency virus (HIV) and antiretroviral treatment on endothelial activation, and the subsequent relationship with cardiovascular disease, is not well understood. We investigated endothelial activation, inflammatory and cardiometabolic profiles, and measures of vascular structure and function of 66 antiretroviral treated (ART), 78 never-treated (no-ART) HIV infected and 165 HIV free Africans.

METHODS

Blood samples were obtained for biochemical analysis and blood pressure, pulse wave velocity (PWV) and carotid intima-media thickness (IMT) measurements were performed.

RESULTS

The HIV infection duration was at least five years and the treatment 2.86±0.13 years. The intracellular adhesion molecule (ICAM) and vascular cell adhesion molecule (VCAM) levels were elevated in the HIV infected groups compared to the controls. The odds of higher adhesion molecule levels were increased when HIV infected (especially in the no-ART group); OR no-ART vs. no-HIV: ICAM 3.92 (2.2-7.0); VCAM 16.2 (7.5-35). ICAM and VCAM associated with HIV status and interleukin-6 (IL-6) in the total group (all p<0.01). In both HIV infected groups VCAM associated inversely with CD4 counts (no-ART: β=-0.28, p=0.01; ART: β=-0.22, p=0.07) and TC (no-ART: β=-0.36, p<0.01; ART: β=-0.27, p=0.03). The ART group had an unfavourable lipid profile compared to the no-ART group. The inflammatory markers (C-reactive protein (CRP) and IL-6), PWV and IMT did not differ between the three groups.

CONCLUSION

HIV infected Africans showed endothelial activation when compared to HIV free controls. The endothelial activation was not accompanied by increased inflammation (as measured with CRP and IL-6), arterial stiffness or sub-clinical atherosclerosis.

Brachial and central blood pressure in HIV-infected subjects

HIV infected subjects present an unfavorable cardiovascular (CV) risk profile that is determined by the infection itself, highly active anti-retroviral therapy (HAART) and other factors, such as chronic kidney disease (CKD). Information is scant and contradictory on whether these factors are associated with arterial stiffness and blood pressure (BP) alteration. Our study aimed to evaluate those parameters in HIV-positive subjects both with and without HAART and with and without CKD, which was defined as the presence of microalbuminuria with a normal glomerular filtration rate. We enrolled 94 HIV-infected subjects without known CV risk factors and compared them with 37 control subjects. We recorded brachial and central BP (pulse wave analysis) and pulse wave velocity ( SphygmoCor). HIV-positive subjects of similar ages and with similar BP values showed central pulse pressure values that were significantly greater than those of controls; this was also the case for the Aix value. Central systolic and pulse pressure values and Aix were significantly greater in HIV-positive subjects with HAART and CKD than in the other HIV-positive subgroups and control subjects. PWV was also superimposable between groups when the data were analyzed relative to the presence of HAART and CKD. Our study shows that the unfavorable CV risk profile associated with HIV infection includes an increase in both central BP and Aix. The central BP increase seems to be favored by renal damage, which apparently has a role in the early stages of the disease.

Carotid intima media thickness is associated with body fat abnormalities in HIV-infected patients

BACKGROUND

HIV-infected patients may be at increased risk of cardiovascular (CV) events, and lipodystrophy is generally associated with proatherogenic metabolic disturbances. Carotid intima-media thickness (cIMT) has been used as a surrogate marker for atherosclerosis and it has been shown to be an independent risk factor for CV disease. Our objective was to evaluate cIMT in HIV-infected patients on combined anti-retroviral therapy (cART) with and without lipodystrophy defined by fat mass ratio (L-FMR), and to determine the association of lipodystrophy and visceral obesity [(visceral (VAT), subcutaneous adipose tissue (SAT) volume and VAT/SAT ratio, objectively evaluated by CT scan] with cIMT.

METHODS

Cross-sectional study of 199 HIV-infected patients. Body composition by DXA and abdominal CT, lipids, blood pressure, inflammatory markers, and cIMT by ultrasonography were performed. L-FMR was defined as the ratio of the percentage of trunk fat mass to the percentage of lower limb fat mass by DXA. Categorical variables were compared using the chi-square or Fisher's exact test. Spearman correlation coefficients were estimated to study the association between cIMT and clinical and metabolic characteristics. Means of cIMT, adjusted for age, were calculated, using generalized linear models.

RESULTS

L-FMR was present in 41.2% of patients and cIMT was higher in these patients [0.81 (0.24) vs. 0.76 (0.25); p=0.037)]. Lipodystrophic patients had higher VAT and VAT/SAT ratio and lower SAT. cIMT was associated with lipodystrophy evaluated by FMR, trunk fat, total abdominal fat, VAT and VAT/SAT ratio. No association was observed between cIMT and leg fat mass. Using generalized linear models, cIMT means were adjusted for age and no significant differences remained after this adjustment. The adjusted mean of cIMT was 0.787 (95%CI: 0.751-0.823) in patients without lipodystrophy, and 0.775 (95%CI: 0.732-0.817) in those with lipodystrophy (p=0.671).

CONCLUSIONS

HIV-infected patients on cART with lipodystrophy defined by FMR, had a significantly higher cIMT. Carotid IMT was also associated with classical cardiovascular risk factors. In these patients, visceral adipose tissue had a significant impact on cIMT, although age was the strongest associated factor.

Pro-atherogenic shear stress and HIV proteins synergistically upregulate cathepsin K in endothelial cells

Major advances in highly active antiretroviral therapies (HAART) have extended the lives of people living with HIV, but there still remains an increased risk of death by cardiovascular diseases (CVD). HIV proteins have been shown to contribute to cardiovascular dysfunction with effects on the different cell types that comprise the arterial wall. In particular, HIV-1 transactivating factor (Tat) has been shown to bind to endothelial cells inducing a range of responses that contribute to vascular dysfunction. It is well established that hemodynamics also play an important role in endothelial cell mediated atherosclerotic development. When exposed to low or oscillatory shear stress, such as that found at branches and bifurcations, endothelial cells contribute to proteolytic vascular remodeling by upregulating cathepsins, potent elastases and collagenases that contribute to altered biomechanics and plaque formation. Mechanisms to understand the influence of Tat on shear stress mediated vascular remodeling have not been fully elucidated. Using an in vivo HIV-Tg mouse model and an in vitro cone and plate shear stress bioreactor to actuate physiologically relevant pro-atherogenic or atheroprotective shear stress on human aortic endothelial cells, we have shown synergism between HIV proteins and pro-atherogenic shear stress to increase endothelial cell expression of the powerful protease cathepsin K, and may implicate this protease in accelerated CVD in people living with HIV.

Pulse wave velocity as index of arterial stiffness in HIV-infected patients compared with a healthy population

BACKGROUND

Chronic HIV infection leads to premature atherosclerosis. Arterial stiffness is considered a subclinical marker of cardiovascular disease.

METHODS

Pulse wave velocity (PWV) was determined in 254 individuals (174 HIV-infected patients and 80 healthy controls, 2:1 matched by age and gender) to compare the prevalence of arterial stiffness and to identify associated factors. PWV was determined using noninvasive automated device (Complior). Factors associated with impaired PWV were assessed among cardiovascular risk factors, HIV infection parameters, and laboratory data. Logistic regression analyses were performed to determine differences between groups and factors associated to arterial stiffness.

RESULTS

Overall, 81.4% of participants were male, median age was 46.54 [interquartile range (IQR): 41-52] years. Higher percentages of HIV-infected subjects showed dyslipemia (P = 0.012) and smoking habit (P = 0.002). The median time from HIV diagnosis was 13 (IQR: 6-18) years and the median time on antiretroviral therapy was 11 (IQR: 5-15) years. Nearly, all patients were virologically suppressed (89.7%) at the time of PWV. Arterial stiffness in the global population was 20.5%, 18.9% in HIV-infected group, and 23.8% in controls (P = 0.405). High diastolic blood pressure and high levels of triglycerides at time of PWV were associated with increased PWV (P = 0.009 and P = 0.023, respectively).

CONCLUSIONS

Virologically suppressed HIV-infected patients showed similar arterial elasticity to non-HIV-infected patients. HIV-related conditions were not associated with arterial stiffness, probably because of the good immunologic and virological status of this group. However, high diastolic pressure at the time of PWV and high levels of triglycerides were associated risk factors.

Infection duration and inflammatory imbalance are associated with atherosclerotic risk in HIV-infected never-smokers independent of antiretroviral therapy

OBJECTIVES

To determine whether the reported increased atherosclerotic risk among HIV-infected individuals is related to antiretroviral therapy (ART) or HIV infection, whether this risk persists in never-smokers, and whether inflammatory profiles are associated with higher risk.

DESIGN

Matched cross-sectional study.

METHODS

A total of 100 HIV-infected patients (50 ART-treated >4 years, 50 ART-naive but HIV-infected >2 years) and 50 HIV-negative controls were recruited in age-matched never-smoking male triads (mean age 40.2 years). Carotid intima-media maximal thickness (c-IMT) was measured across 12 sites. Pro-inflammatory [highly sensitive C-reactive protein (hs-CRP), resistin, interleukin-6, interleukin-18, insulin, serum amyloid A, D-dimer) and anti-inflammatory (total and high molecular weight adiponectin, interleukin-27, interleukin-10) markers were dichotomized into high/low scores (based on median values). c-IMT was compared across HIV/treatment groups or inflammatory profiles using linear regression models adjusted for age, diabetes, hypertension, and, for HIV-infected patients, nadir CD4 cell counts.

RESULTS

Although adjusted c-IMT initially tended to be thicker in ART-exposed patients (P=0.2), in post-hoc analyses stratifying by median HIV duration we observed significantly higher adjusted c-IMT in patients with longer (>7.9 years: 0.760±0.008 mm) versus shorter prevalent duration of known HIV infection (<7.9 years: 0.731±0.008 mm, P=0.02), which remained significant after additionally adjusting for ART (P=0.04). Individuals with low anti-inflammatory profile (<median versus >median score) had thicker c-IMT (0.754±0.006mm versus 0.722±0.006 mm, P<0.001), with anti-inflammatory markers declining as prevalent duration of HIV infection increased (P for linear trend <0.001).

CONCLUSION

Known HIV duration is related to thicker c-IMT, irrespective of ART, in these carefully selected age-matched never-smoking HIV-treated and ART-naive male individuals. Higher levels of anti-inflammatory markers appeared protective for atherosclerosis.

Left ventricular hypertrophy detected by echocardiography in HIV-infected patients

BACKGROUND

Left ventricular hypertrophy (LVH) is a predictor of overall mortality in the general population. The most sensitive diagnostic method is transthoracic echocardiography (TTE). In this study, we describe the prevalence of LVH, and the factors associated with it, in a group of patients with HIV infection.

METHODS

TTE was offered to all patients attending the outpatient clinic of the Hospital Costa del Sol (Marbella, Spain) between 1 December 2009 and 28 February 2011. The corresponding demographic and clinical data were obtained. The left ventricular mass (LVM) was calculated and indexed by height(2.7). LVH was defined as LVM >48g/m(2.7) in men or >44g/m(2.7) in women.

RESULTS

We examined 388 individuals (75.5% male, mean age 45.38years). Of these, 76.1% were receiving HAART; 11.9% had hypertension, 6.2% had diabetes mellitus, 23.2% had dyslipidaemia and 53.6% were tobacco users. The risk of cardiovascular disease at 10years (RV10) was 12.15% (95%CI: 10.99-13.31%). 19.1% of these patients had a high RV10. A total of 69 patients (19.8%) presented high LVM. Age, hypertension, dyslipidaemia, RV10 and the use of nevirapine were associated with a greater presence of LVH in the univariate analysis. In the logistic regression analysis performed, the factors retained in the model were the presence of high RV10 (OR: 2.92, 95%CI: 1.39-6.15) and the use of nevirapine (OR 2.20, 95%CI: 1.18-4.14).

CONCLUSIONS

In this group of patients, the use of nevirapine and the presence of high RV10 were associated with LVH. The use of nevirapine might be related to its prescription for patients with higher RV10.

Poor Aerobic Fitness May Contribute to Cognitive Decline in HIV-infected Older Adults

The HIV-infected older adult (HOA) community is particularly vulnerable to cognitive impairment. Previous studies in the general older adult population have reported that lower scores on tests of cognitive function often correlate negatively with aerobic fitness [5-7]. HIV-infected individuals have significantly reduced aerobic fitness and physical function compared to HIV-uninfected individuals. Determining important correlates of cognitive ability may be beneficial in not only detecting precursors to future cognitive impairments, but also target areas for interventions. The purpose of this study was to investigate the relationship between cognitive ability and aerobic fitness in HIV-infected older adults. We conducted a cross-sectional study of HOA on antiretroviral therapy (ART) >50 years of age. Domain specific cognitive function was assessed by means of a neuropsychological battery. Aerobic fitness (VO2peak) was assessed using a graded, progressive treadmill test. Thirty-seven HOA on ART (mean±SD: age 59±6 years, BMI 28±5, CD4 663±337 cells/ml, duration since HIV diagnosis 17±7 years; 81% males) completed the cognitive tests. Several domains of cognition were significantly associated with VO2peak by Spearman correlation analysis (p<0.05). By step-wise adjusted regression VO2peak was most frequently and significantly related to many cognitive domains such as verbal and visual memory, visual perception, and language (p<0.05). We found that participants with higher Vo2peak were less likely to have more severe forms of HIV-associated neurocognitive disorders (HAND) such as mild neurocognitive disorder (OR=0.65; p=0.01) and HIV-associated dementia (OR=0.64; p=0.0006). In HOA and in conclusion, aerobic fitness is related to cognitive performance on various tasks. The likelihood of cognitive impairment increased with lower fitness levels. Therefore, increased fitness may serve an important factor in maintenance of cognition and neural integrity for aging HIV-infected individuals. Future prospective and large scale studies are needed to evaluate the effect of fitness and vascular stiffness and function on cognition and brain structure among HOA.

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

Introduction

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

Objective

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

Research design and methods

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

Result

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

Conclusion

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

Azidothymidine (AZT) leads to arterial stiffening and intima-media thickening in mice

HIV positive patients on highly active antiretroviral therapy (HAART) have shown elevated incidence of a number of non-AIDS defining co-morbidities, including cardiovascular disease. Given that HAART regimens contain a combination of at least three drugs, that disease management often requires adjustment of these regimens, and HIV, independent of HAART, also plays a role in development of co-morbidities, determining the role of specific HAART drugs and HIV infection itself from clinical data remains challenging. To characterize specific mediators and underlying mechanisms of disease, in vitro and in vivo animal models are required, in parallel with clinical data. Given its low cost azidothymidine (AZT) contributes to the backbone of a large proportion of HAART treated patients in the developing world where much of the global burden of HIV resides. The goal of this study was to test the hypothesis that AZT can lead to proatherogenic changes including the subclinical markers of arterial stiffening and intima-media thickening in mice. AZT (100mg/kg) or vehicle was administered to wild-type FVB/N mice via oral gavage for 35 days. Cylindrical biaxial biomechanical tests on the common carotid arteries and suprarenal aortas exhibited arterial stiffening in AZT mice compared to controls. Multiphoton microscopy and histology demonstrated that AZT led to increased intima-media thickness. These data correlated with decreased elastin content and increased protease activity as measured by cathepsin zymography; no differences were observed in collagen content or organization, in vivo axial stretch, or opening angle. Thus, this study suggests the drug AZT has significant effects on the development of subclinical markers of atherosclerosis.

Nutrition and the HIV-associated lipodystrophy syndrome

HIV-associated lipodystrophy syndrome (HALS), comprising metabolic and morphological alterations, is a known side effect of highly active antiretroviral therapy (HAART). Evidence for the role of nutrition in the management of the systemic parameters of HALS is currently limited. In the present paper we review the current knowledge base surrounding HALS, focusing particularly on the role of nutrition in mitigating the systemic parameters of the syndrome. Reported prevalence of HALS was found to vary from 9 to 83 % due to lack of a standardised definition, as well as variations in assessment methods and in the study population used. HALS is associated with both morphological (lipoatrophy, lipohypertrophy) and metabolic (dyslipidaemia, glucose intolerance, diabetes, hypertension, endothelial dysfunction and atherosclerosis) alterations, which may occur singly or in combination, and are associated with an increased risk of CVD. HAART-induced adipocyte inflammation, oxidative stress and macrophage infiltration, as well as altered adipocyte function and mitochondrial toxicity, have been shown to be central to the development of HALS. The adipocyte, therefore, represents a plausible target for treatment. Pharmacological and surgical treatment interventions have shown effect. However, their use is associated with numerous adverse effects and complications. Targeted lifestyle interventions may provide a useful alternative for managing HALS owing to their safety and tolerability. A Mediterranean-style diet has been found to be effective in improving the systemic parameters of HALS. Furthermore, the effects of n-3 PUFA supplementation are encouraging and future randomised controlled trials investigating the beneficial effects of n-3 PUFA in HALS are justified.

Endothelial dysfunction, arterial stiffening, and intima-media thickening in large arteries from HIV-1 transgenic mice

HIV patients on highly active antiretroviral therapy (HAART) exhibit elevated incidence of cardiovascular disease (CVD), including a higher risk of myocardial infarction and prevalence of atherosclerotic lesions, as well as increases in markers of subclinical atherosclerosis including increased carotid artery intima-media thickness (c-IMT), increased arterial stiffness, and impaired flow-mediated dilation. Both HAART and HIV-infection are independent risk factors for atherosclerosis and myocardial infarction. Studies implicate the HIV proteins tat, gp120, vpu, and nef in early on-set atherosclerosis. The objective of this study was to quantify the role of expression of HIV-1 proteins on the vascular function, biomechanics, and geometry of common carotid arteries and aortas. This study employed NL4-3Δ gag/pol transgenic mice (HIV-Tg), which contain the genetic sequence for the HIV-1 proteins env, tat, nef, rev, vif, vpr, and vpu but lacks the gag and pol genes and reports that HIV-Tg mice have impaired aortic endothelial function, increased c-IMT, and increased arterial stiffness. Further, HIV-Tg arteries show decreased elastin content, increased cathepsin K and cathepsin S activity, and increased mechanical residual stress. Thus, mice that express HIV proteins exhibit pre-clinical markers of atherosclerosis and these markers correlate with changes in markers of vascular remodeling. These findings are consistent with the hypothesis that HIV-proteins, independent of HAART treatment or HIV infection, could play a role in of the development of CVD.

Risk of cardiovascular disease in HIV, hepatitis C, or HIV/hepatitis C patients compared to the general population

BACKGROUND

As a result of effective antiretroviral therapy HIV patients are living longer, and their risk of cardiovascular disease (CVD) is a growing concern. It remains unknown whether coinfection with hepatitis C (HCV) changes an HIV person's CVD risk, and how the risks compare to the general population. The objective of this study was to compare the Framingham Risk Score (FRS) and vascular age differences in persons with HIV, HCV or HIV/HCV disease to the general population.

METHODS

HIV, HCV, and HIV/HCV patients with clinic visits between 2004 and 2009 were sampled from medical clinics in Rochester, NY. Uninfected persons were randomly selected from the National Health and Nutrition Examination Survey (NHANES), and individually matched on gender, race, and age. We stratified by infection group and conducted separate multivariable linear regression analyses between each infection group and the gender, race, and age matched participants from NHANES.

RESULTS

Rochester patients (HIV = 239, HCV = 167, HIV/HCV = 182) were compared 3 : 1 with the NHANES participants. After controlling for weight, marital status, current pharmacotherapies and the matching variables of gender, race, and age, HIV/HCV patients had a 2% higher general FRS compared with the general population (p = 0.03), and vascular age differences that were 4.1 years greater (p = .01). HCV patients had a 2.4% higher general FRS than the general population (p < .001), and vascular age differences that were 4.4 years greater (p < .001). CVD risk was elevated but not significantly different between HIV patients and the general population.

CONCLUSION

Cardiovascular disease risk is elevated among HIV/HCV and HCV infected persons compared with the general population.

Metabolic disorders and cardiovascular consequences of HIV infection and antiretroviral therapy

Metabolic disturbances associated with HIV disease have become an important factor in patient management and have important implications for long-term outcomes, both in regards to mortality and healthcare burden. Recent research has implicated both HIV infection itself and specific antiretroviral therapies in the development of these disorders. This review examines recent findings from research into insulin and glucose dysregulation, serum lipid abnormalities, adipose tissue and derangements in bone metabolism. This review then describes the cardiovascular consequences and management of these metabolic disorders, and summarizes current thinking on the pathogenesis and effects of antiretroviral therapy. Finally, the review raises some questions regarding ongoing challenges and unmet needs in this field of research.

Impaired distensibility of ascending aorta in patients with HIV infection

Background

Our aim was to investigate the aortic distensibility (AD) of the ascending aorta and carotid artery intima-media thickness (c-IMT) in HIV-infected patients compared to healthy controls.

Methods

One hundred and five HIV-infected patients (86 males [82%], mean age 41 ± 0.92 years), and 124 age and sex matched HIV-1 uninfected controls (104 males [84%], mean age 39.2 ± 1.03 years) were evaluated by high-resolution ultrasonography to determine AD and c-IMT. For all patients and controls clinical and laboratory factors associated with atherosclerosis were recorded.

Results

HIV- infected patients had reduced AD compared to controls: 2.2 ± 0.01 vs. 2.62 ± 0.01 10^-6 cm² dyn^-1, respectively (p < 0.001). No difference was found in c-IMT between the two groups. In multiadjusted analysis, HIV infection was independently associated with decreased distensibility (beta –0.45, p < 0.001). Analysis among HIV-infected patients showed that patients exposed to HAART had decreased AD compared to HAART-naïve patients [mean (SD): 2.18(0.02) vs. 2.28(0.03) 10^-6 cm² dyn^-1, p = 0.01]. In multiadjusted analysis, increasing age and exposure to HAART were independently associated with decreased AD.

Conclusion

HIV infection is independently associated with decreased distensibility of the ascending aorta, a marker of subclinical atherosclerosis. Increasing age and duration of exposure to HAART are factors further contributing to decreased AD.

Is arterial stiffness in HIV-infected individuals associated with HIV-related factors?

We investigated the association between pulse wave velocity (PWV) and HIV infection, antiretroviral treatment-related characteristics, viral load, immune status, and metabolic changes in a cross-sectional study nested in a cohort of HIV/AIDS patients who have been followed for metabolic and cardiovascular changes since 2007. The study included patients recruited from the cohort (N = 261) and a comparison group (N = 82) of uninfected individuals, all enrolled from April to November 2009. Aortic stiffness was estimated using the carotid-femoral PWV (Complior-Artech, Paris, France). The groups were similar with respect to age, metabolic syndrome, diabetes mellitus, Framingham score, and use of antihypertensive and hypolipidemic medications. Hypertension was more frequent among the controls. Individuals with HIV had higher triglyceride, glucose and HDL cholesterol levels. Among individuals with HIV/AIDS, those with a nadir CD4⁺ T-cell count <200 cells/mm³ had a higher PWV (P = 0.01). There was no statistically significant difference when subjects were stratified by gender. Heart rate, age, male gender, and blood pressure were independently correlated with PWV. Nadir CD4⁺ T-cell count did not remain in the final model. There was no significance difference in PWV between HIV-infected individuals and uninfected controls. PWV was correlated with age, gender, and blood pressure across the entire population and among those infected with HIV. We recommend cohort studies to further explore the association between inflammation related to HIV infection and/or immune reconstitution and antiretroviral use and PWV.

HIV-1, reactive oxygen species, and vascular complications

Over 1 million people in the United States and 33 million individuals worldwide suffer from HIV/AIDS. Since its discovery, HIV/AIDS has been associated with an increased susceptibility to opportunistic infection due to immune dysfunction. Highly active antiretroviral therapies restore immune function and, as a result, people infected with HIV-1 are living longer. This improved survival of HIV-1 patients has revealed a previously unrecognized risk of developing vascular complications, such as atherosclerosis and pulmonary hypertension. The mechanisms underlying these HIV-associated vascular disorders are poorly understood. However, HIV-induced elevations in reactive oxygen species (ROS), including superoxide and hydrogen peroxide, may contribute to vascular disease development and progression by altering cell function and redox-sensitive signaling pathways. In this review, we summarize the clinical and experimental evidence demonstrating HIV- and HIV antiretroviral therapy-induced alterations in reactive oxygen species and how these effects are likely to contribute to vascular dysfunction and disease.

Imaging atherosclerosis in HIV: carotid intima-media thickness and beyond

Chronic immune activation and inflammation are associated with an increased risk of atherosclerosis in HIV-infected patients. In this review, we discuss the role of established and novel imaging modalities to define more accurately the structure and function of inflammation-mediated atherosclerosis in the context of HIV. Historically, carotid ultrasound studies were the first to show higher rates of subclinical atherosclerosis in HIV-infected subjects versus uninfected controls. However, computed tomography is the noninvasive gold standard for imaging the coronary arteries, and studies in HIV suggest a higher prevalence of noncalcified plaque. Endothelial dysfunction can be quantified by measuring flow-mediated brachial artery dilation by ultrasound and has been used extensively in antiretroviral switching trials and small pilot trials of therapeutics to assess cardiovascular risk in this population. In the future, novel imaging modalities such as intracoronary optical coherence tomography, positron emission tomography imaging of (18)F-fluorodeoxyglucose uptake, and molecular-targeted magnetic resonance imaging will characterize the burden of vulnerable plaque and other unique features of inflammatory atherosclerosis in HIV.

Vascular stiffness and aging in HIV

Large artery stiffening is a biological index of vascular aging. Vascular aging and atherosclerosis are two closely linked processes that develop in parallel and in synergy, sharing common aetiological determinants. Vascular stiffening increases left ventricular work and can lead to diminished coronary perfusion, and may therefore contribute to the development of cardiovascular disease. There is emerging evidence that large artery stiffness and vascular aging are accelerated in HIV infection because of the high prevalence of cardiovascular risk factors among HIV-infected patients. Moreover, the biological effects of HIV and the metabolic perturbations associated with antiretroviral therapies appear to accelerate vascular stiffening in HIV-infected patients. Further studies evaluating the effects of general and targeted therapies and various combinations of antiretroviral therapies on measures of large artery stiffness are urgently needed.

Assessment of vascular function in HIV-infected patients

PURPOSE

The vascular function in HIV-infected persons under HAART and non-HIV-infected persons was investigated.

METHOD

18 HIV-positive patients and 23 HIV-negative subjects (14 younger group and 9 older group) were evaluated for microvascular vasodilatation during postocclusive reactive hyperemia (PORH) and during prolonged local thermal hyperemia; overall microvascular flux increase induced by iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) and large artery stiffness (SI(DVP)).

RESULTS

Cutaneous vascular conductance (CVC) responses to ACh were lower in HIV patients compared to both HIV-negative groups (mean [SEM]) (HIV positive: 878.2 [99.5]; older HIV negative: 1129.3 [231.6]; younger HIV negative: 1366.5 [172.6] % baseline). Regarding SNP iontophoresis, HIV-positive and older HIV-negative groups showed lower CVC responses than younger HIV-negative group (HIV positive: 1043.0 [164.6]; older HIV-negative: 980.8 [108.3]; younger HIV-negative: 1757.3 [245.1] % baseline). Vasodilatation induced by thermal hyperemia (HIV positive: 1.63 [0.11]; older HIV negative: 1.48 [0.08]; younger HIV negative: 1.85 [0.27] perfusion units/mm Hg) and PORH (HIV positive: 0.374 [0.025]; older HIV negative: 0.326 [0.025]; younger HIV negative: 0.326 [0.037] PU/mm Hg) were similar between all groups. SIDVP was greater in HIV and older healthy groups than younger healthy group (HIV positive: 9.17 [0.42]; older HIV negative: 8.19 [0.43]; younger HIV negative: 6.42 [0.22] m/s).

CONCLUSION

HIV-infected patients under HAART exhibited slight but nonsignificant lower microvascular reactivity to pharmacological stimuli and increased arterial stiffness compared to age-matched HIV-negative subjects. Comparison of both HIV-positive and older HIV-negative groups with younger HIV-negative subjects suggests that age plays a major role in microvascular reactivity regardless the HIV-infection.