HIV-associated pulmonary arterial hypertension: from bedside to the future

Pulmonary hypertension survival and hospitalisations in people living with HIV: a systematic review and meta-analysis

INTRODUCTION

People living with HIV (PLHIV) have a higher risk of developing pulmonary hypertension (PH) with subsequent poorer prognosis. This review aimed to determine the (1) survival outcomes and (2) proportion of emergency department (ED) visits and hospitalisations of PLHIV and PH.

METHODS

We conducted a systematic review and meta-analysis of observational studies reporting survival outcomes for PLHIV and PH. Electronic databases (Medline, EMBASE, PubMed, Web of Science, Global Index Medicus and Cochrane Library), trial registries and conference proceedings were searched until 22 July 2023. We pooled similar measures of effect, assessed apriori subgroups and used meta-regression to determine mortality and associated variables.

RESULTS

5248 studies were identified; 28 studies were included with a total of 5459 PLHIV and PH. The mean survival (95% CI) of PLHIV and PH was 37.4 months (29.9 to 44.8). Participants alive at 1, 2 and 3 years were 85.8% (74.1% to 95.0%), 75.2% (61.9% to 86.7%) and 61.9% (51.8% to 71.6%), respectively. ED visits and hospitalisation rates were 73.3% (32.5% to 99.9%) and 71.2% (42.4% to 94.2%), respectively. More severe disease, measured by echocardiogram, was associated with poorer prognosis (β -0.01, 95% CI -0.02 to 0.00, p=0.009). Survival was higher in high-income countries compared with lower-income countries (β 0.50, 95% CI 0.28 to 0.73, p<0.001) and in Europe compared with the America (β 0.56, 95% CI 0.37 to 0.75, p<0.001).

CONCLUSION

Our study confirms poor prognosis and high healthcare utilisation for PLHIV and PH. Prognosis is associated with country income level, geographic region and PH severity. This highlights the importance of screening in this population.

PROSPERO REGISTRATION NUMBER

CRD42023395023.

Management and prognosis of HIV-associated pulmonary arterial hypertension: 20 Years of evidence from the REHAP registry

BACKGROUND

Pulmonary arterial hypertension (PAH) is an independent predictor of death in patients with human immunodeficiency virus (HIV) infection. HIV is the leading cause of PAH (HIV-PAH) worldwide.

AIMS

We described the characteristics, treatment patterns, and prognosis of a cohort of HIV-PAH patients and compared them with those of an equivalent cohort of patients with idiopathic/familial PAH (IPAH/FPAH).

METHODS

We retrospectively analysed and compared the demographic, clinical, and treatment data from patients with HIV-PAH and those with IPAH/FPAH in the Spanish PAH registry (REHAP) from 1998 to 2018. The HIV-PAH overall survival (OS) rate up to 5 years was compared to the age- and sex-matched IPAH/FPAH population. Changes in treatment patterns in patients with HIV-PAH after 2010 and their effects on OS were also analysed.

RESULTS

Compared to those with IPAH/FPAH (n = 739), patients with HIV-PAH (n = 132) were younger, mainly men, and had a better functional status. The clinical presentation, haemodynamics, and respiratory function were similar between the groups. Parenteral drug use was the most common mode of HIV transmission. Approximately 11% of patients with HIV-PAH did not receive PAH-targeted therapy. The age- and sex-adjusted 5-year OS rate from diagnosis was 74.0% for patients with HIV-PAH and 68.7% for those with IPAH (p < 0.159). During/after 2010, 23% of patients with IPAH/FPAH received upfront dual oral combination, while oral monotherapy remained the main first-line treatment in patients with HIV-PAH. The overall OS rate remained stable.

CONCLUSIONS

Patients with HIV-PAH were predominantly young men. The short-term prognosis is similar to that of age- and sex-matched patients with IPAH/FPAH, despite a better functional status. Oral monotherapy remains the preferred first-line treatment in the current cohorts.

Ion channels as convergence points in the pathology of pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a fatal disease of the cardiopulmonary system that lacks curative treatments. The main pathological event in PAH is elevated vascular resistance in the pulmonary circulation, caused by abnormal vasoconstriction and vascular remodelling. Ion channels are key determinants of vascular smooth muscle tone and homeostasis, and four PAH channelopathies (KCNK3, ABCC8, KCNA5, TRPC6) have been identified so far. However, the contribution of ion channels in other forms of PAH, which account for the majority of PAH patients, has been less well characterised. Here we reason that a variety of triggers of PAH (e.g. BMPR2 mutations, hypoxia, anorectic drugs) that impact channel function may contribute to the onset of the disease. We review the molecular mechanisms by which these ‘extrinsic’ factors converge on ion channels and provoke their dysregulation to promote the development of PAH. Ion channels of the pulmonary vasculature are therefore promising therapeutic targets because of the modulation they provide to both vasomotor tone and proliferation of arterial smooth muscle cells.

Assessment of Pulmonary Arterial Hemodynamic and Vascular Changes by Pulmonary Pulse Transit Time in Patients with Human Immunodeficiency Virus Infection

Introduction

Pulmonary arterial hypertension and human immunodeficiency virus (HIV) infection is a well-known association. Pulmonary pulse transit time (pPTT) is a recent echocardiographic marker that might be used for evaluation of pulmonary arterial stiffness (PAS) in patients with HIV infection. We aimed to investigate whether pPTT elevated in patients with HIV infection compared to healthy controls and its association with echocardiographic indices of right ventricular functions.

Materials and Methods

Fifty HIV (+) patients from infectious disease outpatient clinics and fifty age- and sex-matched HIV (-) healthy volunteers were enrolled in this study. pPTT was measured from pulmonary vein flow velocity as the time interval between the R-wave in the electrocardiography and corresponding peak late systolic was then calculated as the mean from two separate pw-Doppler measurements.

Results

pPTT, tricuspid annular peak systolic excursion (TAPSE) and right ventricle fractional area change (FAC) were significantly lower in patients with HIV than control patients (177.1 ± 34.9 vs. 215.7 ± 35.7 msn, P < 0.001; 2.33 ± 0.28 vs. 2.19 ± 0.22, P = 0.039; 45 [4.25] vs. 41.1 [4.0], P = 0.032, respectively). pPTT was positively correlated with FAC, TAPSE and cluster of differentiation 4 count (r = 0.210; P = 0.036, r = 0.256; P = 0.041, r = 0.304; P = 0.044, respectively).

Conclusion

Our study showed that pPTT, TAPSE, and right ventricle FAC levels were lower in patients with HIV infection. pPTT is an important predictor in patients with HIV expected to develop pulmonary vascular pathology.

Infection, atherothrombosis and thromboembolism beyond the COVID-19 disease: what similar in physiopathology and researches

The recent Sars-Cov-2 pandemic (COVID-19) has led to growing research on the relationship between thromboembolism and Sars-Cov-2 infection. Nowadays, endothelial dysfunction, platelet activation, coagulation, and inflammatory host immune response are the subject of extensive researches in patients with COVID-19 disease. However, studies on the link between microorganisms or infections and thrombotic or thromboembolic events met fluctuating interest in the past. We, therefore, aimed to briefly summarize previous evidence on this topic, highlighting common points between previous data and what experienced today with SARS-COV2 infections.

Noninvasive detection of impaired pulmonary artery endothelial function in people living with HIV

OBJECTIVE

People living with HIV (PLWH) have an increased risk of pulmonary vascular disease and pulmonary hypertension. Endothelial cell dysfunction is thought to contribute, but human studies have been limited by the invasive nature of conventional measures of pulmonary artery endothelial function (PAEF). We report here a noninvasive MRI approach to measure nitric oxide mediated PAEF by quantifying changes in pulmonary artery area and blood flow during isometric handgrip exercise (IHE), an endothelial nitric oxide dependent stressor. We used this to test the hypothesis that PLWH have impaired PAEF, even before development of pulmonary hypertension.

DESIGN

A prospective cohort study.

METHODS

We enrolled 25 HIV-positive viral-suppressed individuals on stable antiretroviral therapy without known or suspected pulmonary hypertension and 19 matched seronegative control individuals (HIV-negative). Pulmonary artery area and blood flow changes in response to IHE were measured with noncontrast MRI. Data previously collected during nitric oxide-synthase inhibition were analysed to determine the role of nitric oxide in the pulmonary artery response to IHE.

RESULTS

Seronegative individuals exhibited the anticipated PA vasodilatory response to IHE, but this was completely absent in HIV-positive individuals who exhibited an impaired area change (-1.1 ± 1.2 vs. +7.7 ± 2.2%, HIV-positive vs. HIV-negative, mean ± SEM, respectively, P = 0.002) and blood flow response (0.2 ± 2.3 vs. 13.5 ± 4.8%, P = 0.005). The pulmonary artery vasodilatory effect of IHE in healthy individuals was fully blocked by nitric oxide-synthase, demonstrating this pulmonary artery response is predominantly nitric oxide mediated.

CONCLUSION

Using noninvasive MRI methods to quantify PAEF, we observed significantly impaired PAEF in PLWH compared with matched HIV-negative controls. Noninvasive PAEF testing may be useful in evaluating early HIV-related pulmonary vascular disease.

Patho-immune Mechanisms of Hypertension in HIV: a Systematic and Thematic Review

PURPOSE OF REVIEW

To systematically review recent findings on the role of immune cell activation in the pathogenesis of hypertension in people living with HIV (PLWH) and compare studies from Sub-Saharan Africa with what is reported in the USA and European literature according to guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RECENT FINDINGS

PLWH have an increased risk for development of hypertension and cardiovascular disease. Chronic immune activation contributes to hypertension but the inflammatory milieu that predisposes PLWH to hypertension is poorly understood. We identified 45 relevant studies from 13 unique African countries. The prevalence of hypertension in PLWH on antiretroviral therapy (ART) and the ART-naive PLWH ranged from 6 to 50% and 2 to 41%, respectively. Interleukin (IL)-17A, interferon (IFN)-γ, and higher CD4+ T cell counts were associated with hypertension in ART-treated participants. Targeting adaptive immune activation could provide improved care for hypertensive PLWH. Further research is needed to characterize the inflammatory milieu contributing to hypertension in PLWH especially in African populations where the global burden of HIV is the highest.

Pharmacokinetic interaction of riociguat and antiretroviral combination regimens in HIV-1-infected adults

Riociguat, a first-in-class soluble guanylate cyclase stimulator, is approved for the treatment of pulmonary arterial hypertension (PAH), a serious potential complication of human immunodeficiency virus (HIV) infection. This open-label study investigated the pharmacokinetic drug–drug interaction potential of antiretroviral therapies on riociguat exposure in HIV-infected adults. HIV-infected adults without PAH on stable antiretroviral regimens (efavirenz/emtricitabine/tenofovir disoproxil, emtricitabine/rilpivirine/tenofovir disoproxil, elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil, abacavir/dolutegravir/lamivudine, or a ritonavir-boosted triple regimen) for ≥ 6 weeks received a single riociguat dose (0.5 mg). Riociguat pharmacokinetics and safety were assessed; pharmacokinetics was compared with historical healthy volunteer data. Of 41 participants treated (n = 8 in each arm, except n = 9 in the ritonavir-boosted triple regimen arm), 40 were included in the pharmacokinetic analyses. Riociguat median t_max was 1.00–1.27 h, with comparable maximum concentration (C_max) across the five background antiretroviral groups. Riociguat exposure was highest with abacavir/dolutegravir/lamivudine, followed by elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil > emtricitabine/rilpivirine/tenofovir disoproxil > ritonavir-boosted triple regimen > efavirenz/emtricitabine/tenofovir disoproxil; riociguat area under the plasma concentration versus time curve (AUC) was approximately threefold higher with abacavir/dolutegravir/lamivudine than efavirenz/emtricitabine/tenofovir disoproxil. Compared with historical data, riociguat exposure in HIV-infected adults was similar when co-administered with efavirenz/emtricitabine/tenofovir disoproxil, slightly increased when administered with ritonavir-boosted triple regimen and increased by approximately threefold when administered with abacavir/dolutegravir/lamivudine. Riociguat was well tolerated, with no new safety findings. Riociguat was well tolerated in adults with HIV on stable background antiretroviral therapy although an apparent increase in AUC of riociguat was observed in patients receiving abacavir/dolutegravir/lamivudine. Patients should be monitored closely during riociguat initiation and dose adjustment for signs and symptoms of hypotension.

Drug abuse and HIV-related pulmonary hypertension: double hit injury

: Improved survival among HIV-1-infected individuals with the advent of antiretroviral therapy has clearly led to a greater prevalence of noninfectious complications. One of the most devastating sequelae in these individuals is the development of pulmonary arterial hypertension (PAH). Various epidemiological studies suggest worse survival of HIV-PAH patients when compared with other forms of PAH. Given that only a subset and not all HIV-infected individuals develop HIV-PAH, it is suggested that an additional second-hit of genetic or environmental trigger is needed for the development of PAH. In this context, it has been well documented that HIV patients who abuse illicit drugs such as stimulants, opioids, and the like, are more susceptible to develop PAH. In this review, we highlight the studies that support the significance of a double hit of HIV and drug abuse in the incidence of PAH and focus on the research that has been undertaken to unravel the pathobiology and vascular remodeling mechanisms underlying the deleterious synergy between HIV infection and drugs of abuse in orchestrating the development of PAH.

HIV transgene expression impairs K+ channel function in the pulmonary vasculature

Human immunodeficiency virus (HIV) infection is an established risk factor for pulmonary arterial hypertension (PAH); however, the pathogenesis of HIV-related PAH remains unclear. Since K⁺ channel dysfunction is a common marker in most forms of PAH, our aim was to analyze whether the expression of HIV proteins is associated with impairment of K⁺ channel function in the pulmonary vascular bed. HIV transgenic mice (Tg26) expressing seven of the nine HIV viral proteins and wild-type (WT) mice were used. Hemodynamic assessment was performed by echocardiography and catheterization. Vascular reactivity was studied in endothelium-intact pulmonary arteries. K⁺ currents were recorded in freshly isolated pulmonary artery smooth muscle cells (PASMC) using the patch-clamp technique. Gene expression was assessed using quantitative RT-PCR. PASMC from Tg26 mice had reduced K⁺ currents and were more depolarized than those from WT. Whereas voltage-gated K⁺ channel 1.5 (Kv1.5) currents were preserved, pH-sensitive noninactivating background currents ( I_KN) were nearly abolished in PASMC from Tg26 mice. Tg26 mice had reduced lung expression of Kv7.1 and Kv7.4 channels and decreased responses to the Kv7.1 channel activator L-364,373 assessed by vascular reactivity and patch-clamp experimental approaches. Although we found pulmonary vascular remodeling and endothelial dysfunction in Tg26 mice, this was not accompanied by changes in hemodynamic parameters. In conclusion, the expression of HIV proteins in vivo impairs pH-sensitive I_KN and Kv7 currents. This negative impact of HIV proteins in K⁺ channels was not sufficient to induce PAH, at least in mice, but may play a permissive or accessory role in the pathophysiology of HIV-associated PAH.

Notch3/VEGF-A axis is involved in TAT-mediated proliferation of pulmonary artery smooth muscle cells: Implications for HIV-associated PAH

The incidence of pulmonary arterial hypertension (PAH) is a significant co-morbidity observed in HIV (+) individuals. Pulmonary artery smooth muscle cells (PASMCs)—key components of the arterial vessel wall that regulate vessel diameter, demonstrate increased proliferation and hypertrophy in the lungs of HIV infected individuals, underscoring the role of these cells in the pathogenesis of HIV-associated PAH. While several pathways have been implicated in enhanced proliferation of PASMCs, detailed molecular mechanism(s) underlying HIV-associated PASMC proliferation still remain elusive. In the current study, we sought to investigate the effects HIV protein transactivator of transcription (TAT)-mediated proliferation on PASMCs. In agreement with earlier findings, our results also demonstrated TAT-mediated proliferation of human PASMCs. We identified activation of a novel Notch3 signaling pathway in TAT-mediated proliferation of PASMCs. Further validation of the Notch 3 pathway was demonstrated using both pharmacological (γ-secretase inhibitor, DAPT), as well as genetic approaches (Notch3 siRNA). Vascular endothelial growth factor A (VEGF-A) was identified as a novel downstream molecule that was induced following Notch activation. Findings from in vitro studies were further validated in archived simian immunodeficiency virus (SIV)-infected monkey lung tissues. There was increased activation of Notch3 signaling as well as enhanced expression of VEGF-A in the lungs of SIV-infected macaques compared with the lungs of SIV(−) controls. Taken together, we demonstrated that HIV-TAT increased the proliferation of PASMCs via the Notch3/VEGF-A axis. Targeting the Notch3/VEGF-A axis could thus be considered a potential therapeutic approach for the treatment of HIV-associated PAH.

Inflammasomes: a novel therapeutic target in pulmonary hypertension?

Pulmonary hypertension (PH) is a rare, progressive pulmonary vasculopathy characterized by increased mean pulmonary arterial pressure, pulmonary vascular remodelling and right ventricular failure. Current treatments are not curative, and new therapeutic strategies are urgently required. Clinical and preclinical evidence has established that inflammation plays a key role in PH pathogenesis, and recently, inflammasomes have been suggested to be central to this process. Inflammasomes are important regulators of inflammation, releasing the pro-inflammatory cytokines IL-1β and IL-18 in response to exogenous pathogen- and endogenous damage-associated molecular patterns. These cytokines are elevated in PH patients, but whether this is a consequence of inflammasome activation remains to be determined. This review will briefly summarize current PH therapies and their pitfalls, introduce inflammasomes and the mechanisms by which they promote inflammation and, finally, highlight the preclinical and clinical evidence for the potential involvement of inflammasomes in PH pathobiology and how they may be targeted therapeutically. LINKED ARTICLES: This article is part of a themed section on Immune Targets in Hypertension. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.12/issuetoc.

The role of HIV Tat protein in HIV-related cardiovascular diseases

The human immunodeficiency virus (HIV) is a major global public health issue. HIV-related cardiovascular disease remains a leading cause of morbidity and mortality in HIV positive patients. HIV Tat is a regulatory protein encoded by tat gene of HIV-1, which not only promotes the transcription of HIV, but it is also involved in the pathogenesis of HIV-related complications. This review is aimed at summarizing the current understanding of Tat in HIV-related cardiovascular diseases.

Pulmonary Diseases in Refugees and Migrants in Europe

More than 2 million people fleeing conflict, persecution, and poverty applied for asylum between 2015 and 2016 in the European Union. Due to this, medical practitioners in recipient countries may be facing a broader spectrum of conditions and unusual presentations not previously encountered, including a wide range of infections with pulmonary involvement. Tuberculosis is known to be more common in migrants and has been covered broadly in other publications. The scope of this review was to provide an overview of exotic infections with pulmonary involvement that could be encountered in refugees and migrants and to briefly describe their epidemiology, diagnosis, and management. As refugees and migrants travel from numerous countries and continents, it is important to be aware of the various organisms that might cause disease according to the country of origin. Some of these diseases are very rare and geographically restricted to certain regions, while others have a more cosmopolitan distribution. Also, the spectrum of severity of these infections can vary from very benign to severe and even life-threatening. We will also describe infectious and noninfectious complications that can be associated with HIV infection as some migrants might originate from high HIV prevalence countries in sub-Saharan Africa. As the diagnosis and treatment of these diseases can be challenging in certain situations, patients with suspected infection might require referral to specialized centers with experience in their management. Additionally, a brief description of noncommunicable pulmonary diseases will be provided.

Non-infectious Pulmonary Diseases and HIV

Pulmonary complications remain among the most frequent causes of morbidity and mortality for individuals with HIV despite the advent of antiretroviral therapy (ART) and improvement in its efficacy and availability. The prevalence of non-infectious pulmonary diseases is rising in this population, reflecting both an increase in smoking and the independent risk associated with HIV. The unique mechanisms of pulmonary disease in these patients remain poorly understood, and direct effects of HIV, genetic predisposition, inflammatory pathways, and co-infections have all been implicated. Lung cancer, chronic obstructive pulmonary disease (COPD), and pulmonary hypertension are the most prevalent non-infectious pulmonary diseases in persons with HIV, and the risk of each of these diseases is higher among HIV-infected (HIV+) persons than in the general population. This review discusses the latest advances in the literature on these important complications of HIV infection.

HIV Infection and Risk of Cardiovascular Diseases Beyond Coronary Artery Disease

PURPOSE OF REVIEW

Cardiovascular disease (CVD) increasingly afflicts people living with HIV (PLWH) in the contemporary era of antiretroviral therapy (ART). Coronary artery disease (CAD) is the most widely studied cardiovascular problem in PLWH; however, less is known about other clinically relevant subtypes of CVD such as heart failure (HF), cerebrovascular disease, sudden cardiac death, pericardial diseases, and pulmonary hypertension. This paper reviews evidence of other subtypes of CVD as emerging issues in the post-ART era.

RECENT FINDINGS

Recent studies have shown that PLWH have higher risk of HF as well as subclinical impairment of left ventricular (LV) mechanics (systolic and diastolic dysfunction) and myocardial abnormalities (fibrosis and steatosis). The underlying mechanisms, however, are not well-understood. A few studies have also shown higher rates of atrial fibrillation and sudden cardiac death in PLWH. Ischemic stroke is the most common stroke type in the post-ART era, with underlying mechanisms like those identified in CAD: chronic inflammation and associated vasculopathy. Studies of great vessels (carotid artery and aorta) and peripheral arterial disease show heterogeneous results. Small subclinical pericardial effusions are common in PLWH in post-ART era. Pulmonary hypertension continues to be an underdiagnosed and potentially fatal complication of HIV infection. PLWH remain at higher risk for all types of CVD including heart failure, stroke, and arrhythmias in the post-ART era. Chronic inflammation may play an important role in this increased risk. More studies are needed to further elucidate the extent of non-coronary CVD in PLWH and the underlying mechanisms for them.

Coexpression Analysis of Transcriptome on AIDS and Other Human Disease Pathways by Canonical Correlation Analysis

Acquired immune deficiency syndrome is a severe disease in humans caused by human immunodeficiency virus. Several human genes were characterized as host genetic factors that impact the processes of AIDS disease. Recent studies on AIDS patients revealed a series disease is complicating with AIDS. To resolve gene interaction between AIDS and complicating diseases, a canonical correlation analysis was used to identify the global correlation between AIDS and other disease pathway genes expression. The results showed that HLA-B, HLA-A, MH9, ZNED1, IRF1, TLR8, TSG101, NCOR2, and GML are the key AIDS-restricted genes highly correlated with other disease pathway genes. Furthermore, pathway genes in several diseases such as asthma, autoimmune thyroid disease, and malaria were globally correlated with ARGs. It suggests that these diseases are a high risk in AIDS patients as complicating diseases.

Non-infectious pulmonary disorders in HIV

INTRODUCTION

Since the advent of antiretroviral therapy (ART), non-infectious pulmonary disorders have become common comorbidities in the human immunodeficiency virus (HIV) positive population. Clinicians caring for those with HIV disease should be aware of the prevalence of non-infectious pulmonary disorders. A comprehensive understanding is required to diagnosis and manage these syndromes appropriately. Areas covered: This review focuses on the epidemiology, risk factors, pathogenesis, clinical feature and diagnosis, and treatment of HIV-related chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary hypertension. Expert Commentary: The prevalence of COPD in the HIV population is frequent and requires appropriate diagnosis and treatment. HIV-positive individuals with lung cancer carry a poorer prognosis and require early diagnosis and treatment. A complex condition exists with pulmonary hypertension in the HIV population and requires a high degree of clinical suspicion for early diagnosis.

Maintaining lung health with longstanding HIV

PURPOSE OF REVIEW

Human immunodeficiency virus (HIV) is now managed as a chronic disease. Non-infectious pulmonary conditions have replaced infection as the biggest threat to lung health, particularly as HIV cohorts age, but there is no consensus on how best to maintain long-term lung health. We review the epidemiology and pathogenesis of chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension (PAH), and lung cancer in HIV-seropositive individuals.

RECENT FINDINGS

Diagnoses of COPD are now up to 50% more prevalent in HIV-seropositive individuals than HIV-uninfected controls, and prospective pulmonary function studies find significant impairment in 7% to more than 50% of HIV-seropositive individuals. The prevalence of HIV-PAH is 0.2-0.5%, and lung cancer is two to three times more prevalent in HIV-seropositive individuals. Although host factors such as age and smoking have a role, HIV is an independent contributor to the pathogenesis of COPD, PAH, and lung cancer. Chronic inflammation, immune senescence, oxidative stress, and direct effects of viral proteins are all potential pathogenetic mechanisms. Despite their prevalence, non-infectious lung diseases remain underrecognized and evidence for effective screening strategies in HIV-seropositive individuals is limited.

SUMMARY

COPD, PAH, and lung cancer are a growing threat to lung health in the highly active antiretroviral therapy era necessitating early recognition.

Prevalence and incidence of pulmonary hypertension among HIV-infected people in Africa: a systematic review and meta-analysis

OBJECTIVE

Patients infected with HIV have a direly increased risk of developing pulmonary hypertension (PH), and of dying from the condition. While Africa carries the greatest burden of HIV infection worldwide, there is unclear data summarising the epidemiology of PH among HIV-infected people in this region. Our objective was to determine the prevalence and incidence of PH among HIV-infected people living across Africa.

DESIGN

A systematic review and meta-analysis.

PARTICIPANTS

HIV-infected African people residing in Africa.

OUTCOME

Prevalence and incidence of PH diagnosed through echocardiography or right heart catheterisation.

DATA SOURCES

Articles published in PubMed/MEDLINE, EMBASE, African Journals Online and African Index Medicus between 1 January 1980 and 30 June 2016, without any language restriction.

RESULTS

Overall, 121 studies were screened; 3 were included in this review: 1 from Southern Africa (South Africa), 1 from Eastern Africa (Tanzania) and 1 from Central Africa (Cameroon). These studies included HIV-infected adult patients selected based on presentation with cardiovascular symptoms. No study reported PH incidence or PH incidence/prevalence among children and adolescents. The quality assessment yielded moderate risk of bias. Ages of participants ranged between 18 and 78 years, and the proportion of females varied between 52.3% and 68.8%. The prevalence of PH in the pooled sample of 664 patients was 14% (95% CI 6%-23%).

LIMITATIONS

Only 3 studies were found eligible from 3 regions of the African continent.

CONCLUSIONS

The prevalence of PH among HIV-infected people in Africa seems very high. Further studies are urgently warranted to determine the incidence of HIV-induced PH, which must include all subregions of Africa.

TRIAL REGISTRATION NUMBER

Review registration number PROSPERO CRD42016033863.

HIV Infection and Primary Prevention of Cardiovascular Disease: Lights and Shadows in the HAART Era

With the progressive increase in life-expectancy of human immunodeficiency virus (HIV)-positive patients in the "highly active antiretroviral therapy" (HAART) era, co-morbidities, particularly cardiovascular (CV) diseases (CVD) are emerging as an important concern. The pathophysiology of CVD in this population is complex, due to the interaction of classical CV risk factors, viral infection and the effects of antiretroviral therapy (ARV). The role of ARV drugs in HIV is double edged. While these drugs reduce systemic inflammation, an important factor in CV development, they may at the same time be proatherogenic by inducing dyslipidemia, body fat redistribution and insulin resistance. In these patients primary prevention is challenging, considering the lower median age at which acute coronary syndromes occur. Furthermore prevention is still limited by the lack of robust evidence-based, HIV-specific recommendations. Therefore we performed a comprehensive evaluation of the literature to analyze current knowledge on CVD prevalence in HIV-infected patients, traditional and HIV-specific risk factors and risk stratification, and to summarize the recommendations for primary prevention of CVD in this HIV population.

[Pulmonary arterial hypertension associated with human immunodeficiency virus infection: study of 4 cases]

BACKGROUND AND OBJECTIVE

Pulmonary arterial hypertension (PAH) is a rare and progressive disease that can be inherited as autosomal dominant form. The BMPR2, ACVRL1 and ENG genes are main genes involved in the pathology. PAH associated to human immunodeficiency virus (HIV) is another rare disease with a low incidence, prevalence and survival. The main objective of this analysis was to study the clinical and molecular characteristics of PAH associated to HIV patients.

PATIENTS

We present 4 cases of HIV patients who developed PAH and have been treated with ambrisentan.

RESULTS

Pathogenic mutations have been identify in analyzed genes in 3 of the four analyzed patients. In addition, these patients present other changes classified as benign after a thorough in silico analysis. We identified some changes in genetic modifiers that predispose to these patients to more severe phenotype.

CONCLUSIONS

The clinical analysis can help to define monitoring for these patients and the administration of appropriate treatment. These patients also have shown several pathogenic mutations.

HIV related pulmonary arterial hypertension: epidemiology in Africa, physiopathology, and role of antiretroviral treatment

The development of HIV related pulmonary arterial hypertension (PAH) reduces the probability of survival by half as compared with HIV-infected individuals without HIV related PAH. HIV infected patients have a greater incidence of PAH compared to general population and have a 2500-fold increased risk of developing PAH. It is therefore important to have a recent overview of the problem in Africa, the most HIV affected part of the world (70 % of all HIV infection in the world). First, we discussed the epidemiology of HIV-related PAH in Africa. Second, the current understanding of the HIV-related PAH pathogenesis has been covered. Third, role of highly active antiretroviral therapy on HIV-related PAH has been revisited. There are few data concerning epidemiology of HIV related pulmonary hypertension in Africa leading to necessity to conduct further prospective large studies. The prevalence of PAH among HIV infected people in Africa varies from 5 to 13 %. The prevalence of HIV-related PAH in Africa is notably high compared to those in developed countries and in general population. The pathogenesis of PAH is clearly complex, and probably results from the interaction of multiple modulating genes with environmental factors. The physiopathology includes cytokines secretion increase which induces dysregulation of endothelial and vascular smooth muscle cell growth and imbalance of endogenous vasodilators and constrictors; HIV viral proteins which induces vascular oxidative stress, smooth myocyte proliferation and migration, and endothelial injury and genetic predisposition due to some major histocompatibility complex alleles, particularly HDL-DR6 and HLA-DR5. Histologically, HIV related PAH has the same characteristics with other types PAH. Antiretroviral therapy have a beneficial effect on the outcome of HIV related pulmonary hypertension, but it lacks evidence from large prospective studies.