Gender differences in the use of cardiovascular interventions in HIV-positive persons; the D:A:D Study

Evolving mechanisms and presentations of cardiovascular disease in people with HIV: implications for management

People with HIV (PWH) are at elevated risk for cardiovascular diseases (CVDs), including myocardial infarction, heart failure, and sudden cardiac death, among other CVD manifestations. Chronic immune dysregulation resulting in persistent inflammation is common among PWH, particularly those with sustained viremia and impaired CD4+ T cell recovery. This inflammatory milieu is a major contributor to CVDs among PWH, in concert with common comorbidities (such as dyslipidemia and smoking) and, to a lesser extent, off-target effects of antiretroviral therapy. In this review, we discuss the clinical and mechanistic evidence surrounding heightened CVD risks among PWH, implications for specific CVD manifestations, and practical guidance for management in the setting of evolving data.

Monocyte-derived Dll4 is a novel contributor to persistent systemic inflammation in HIV patients

Background

In people living with HIV (PLWH) on combination antiretroviral therapy (cART), persistent systemic inflammation is a driving force for the progression of comorbidities, such as cardiovascular and cerebrovascular diseases. In this context, monocyte- and macrophage-related inflammation rather than T cell activation is a major cause of chronic inflammation. However, the underlying mechanism of how monocytes cause persistent systemic inflammation in PLWH is elusive.

Methods and Results

In vitro, we demonstrated that lipopolysaccharides (LPS) or tumor necrosis factor alpha (TNFα), induced a robust increase of Delta-like ligand 4 (Dll4) mRNA and protein expression in human monocytes and Dll4 secretion (extracellular Dll4, exDll4) from monocytes. Enhanced membrane-bound Dll4 (mDll4) expression in monocytes triggered Notch1 activation to promote pro-inflammatory factors expression. Dll4 silencing and inhibition of Nocth1 activation diminished the LPS or TNFα -induced inflammation. exDll4 releases in response to cytokines occurred in monocytes but not endothelial cells or T cells. In clinical specimens, we found that PLWH, both male and female, on cART, showed a significant increase in mDll4 expression, activation of Dll4-Notch1 signaling, and inflammatory markers in monocytes. Although there was no sex effect on mDII4 in PLWH, plasma exDll4 was significantly elevated in males but not females compared to HIV uninfected individuals. Furthermore, exDll4 plasma levels paralleled with monocytes mDll4 in male PLWH. Circulating exDll4 was also positively associated with pro-inflammatory monocytes phenotype and negatively associated with classic monocytes phenotype in male PLWH.

Conclusion

Pro-inflammatory stimuli increase Dll4 expression and Dll4-Notch1 signaling activation in monocytes and enhance monocyte proinflammatory phenotype, contributing to persistent systemic inflammation in male and female PLWH. Therefore, monocyte mDll4 could be a potential biomarker and therapeutic target of systemic inflammation. Plasma exDll4 may also play an additional role in systemic inflammation but primarily in men.

Cardiovascular disease risk in women living with HIV

PURPOSE OF REVIEW

To synthesize current evidence on the impact of cardiovascular disease among women living with HIV (WLWH) with a particular focus on disease prevalence, mechanisms and prevention.

RECENT FINDINGS

HIV-related cardiovascular disease risk is 1.5-fold to 2-fold higher for women than for men. Mechanisms of enhanced risk are multifactorial and include reinforcing pathways between traditional risk factors, metabolic dysregulation, early reproductive aging and chronic immune activation. These pathways influence both the presentation of overt syndromes of myocardial infarction, stroke and heart failure, as well as subclinical disease, such as microvascular dysfunction and cardiac fibrosis. Cardiovascular disease, therefore, remains a consistent threat to healthy aging among WLWH.

SUMMARY

Although no specific prevention strategies exist, patient-centered risk mitigation approaches that are adaptable to the needs of aging individuals are essential to combat disparities in cardiovascular outcomes among WLWH. Further research into the optimal prevention approach for CVD among WLWH, particularly for women living in under-resourced health systems, is needed.

Comorbidities in women living with HIV: A systematic review

Objectives

Effective antiretroviral therapy (ART) has improved the life expectancy of women living with HIV (WLWH). This population is now experiencing age‐related comorbidities. This systematic review presents the current understanding of the prevalence and impact of comorbidities in WLWH in the modern ART era.

Methods

MEDLINE and Embase were searched for studies (1 January 2010 to 1 September 2020) reporting the prevalence of cardiovascular, bone, renal and neurocognitive disease in WLWH aged > 18 years. Studies were included if at least 100 participants (or > 50%) were female and data analysis included prevalence by sex.

Results

In all, 3050 articles were identified and screened; 153 full‐text articles were assessed for eligibility and 38 were included in the final review. Significant gaps in the literature were identified, notably a lack of data on WLWH aged > 50 years. The data suggest a high burden of cardiovascular, bone, renal and neurocognitive disease in WLWH compared with HIV negative women. Traditional risk factors, such as hypertension, diabetes and dyslipidaemia, were common and often poorly managed. Generalizability of the results was limited, as many studies were conducted in the USA. Comparisons between WLWH and men with HIV were limited by marked differences in demographic and socioeconomic factors.

Conclusions

Women living with HIV experience a high burden of comorbid disease. Traditional risk factors are common and often poorly managed. This review also highlights the magnitude of differences between women and men living with HIV beyond the pathophysiological. Future research must unpick the complex drivers of morbidity in WLWH, to improve the holistic management of this population.

Cardiovascular disease and prevention among people living with HIV in South Florida

Antiretroviral therapy (ART) has improved survival of patients living with HIV (PLWH); however, this has been accompanied by an increase in cardiovascular disease (CVD). Although preventative measures for CVD among the general population are well described, information is limited about CVD prevention among PLWH. The goal of this study was to characterize the prevalence of CVD in our population and to assess the use of primary and secondary prevention.We performed a retrospective review of PLWH receiving primary care at a large academic center in Miami, Florida. We characterized the prevalence of CVD, CVD risk, and the use of aspirin and statins for primary and secondary CVD prevention.A total of 985 charts were reviewed (45% women, 55% men). Average age was 52.2 years. Average CD4 count was 568 cells/microL. 92.9% were receiving ART, and 71% were virologically suppressed. The median 10-year ASCVD risk was 7.3%. The prevalence of CVD was 10.4% (N = 102). The odds of having CVD was lower in patients on ART (OR 0.47, 95% CI: 0.25-0.90, P = .02). The use of medications for primary and secondary prevention of CVD based on current guidelines was low: 15% and 37% for aspirin respectively, and 25% and 44% for statins.CVD risk and rates of CVD are high among PLWH and receiving ART could protect against CVD. However, the use of medications for primary and secondary prevention is low. Increased awareness of CVD risk-reduction strategies is needed among providers of PLWH to decrease the burden of CVD.

Incidence of dyslipidemia in people with HIV who are treated with integrase inhibitors versus other antiretroviral agents

OBJECTIVE

To compare the incidence of dyslipidemia in people with HIV receiving integrase inhibitors (INSTI) versus boosted protease inhibitors (PI/b) and nonnucleoside reverse transcriptase inhibitors (NNRTI) within RESPOND consortium of prospective cohorts.

METHODS

Participants were eligible if they were at least 18 years, without dyslipidemia and initiated or switched to a three-drug antiretroviral therapy (ART)-regimen consisting of either INSTI, NNRTI, or PI/b for the first time, between 1 January 2012 and 31 December 2018. Dyslipidemia was defined as random total cholesterol more than 240 mg/dl, HDL less than 35 mg/dl, triglyceride more than 200 mg/dl, or initiation of lipid-lowering therapy. Poisson regression was used to determine the adjusted incidence rate ratios. Follow-up was censored after 3 years or upon ART-regimen discontinuation or last lipid measurement or 31 December 2019, whichever occurred first.

RESULTS

Overall, 4577 people with HIV were eligible (INSTI = 66.9%, PI/b = 12.5%, and NNRTI = 20.6%), 1938 (42.3%) of whom were ART-naive. During 1.7 (interquartile range, 0.6-3.0) median years of follow-up, 1460 participants developed dyslipidemia [incidence rate: 191.6 per 1000 person-years, 95% confidence interval (CI) 182.0-201.7]. Participants taking INSTI had a lower incidence of dyslipidemia compared with those on PI/b (adjusted incidence rate ratio 0.71; CI 0.59-0.85), but higher rate compared with those on NNRTI (1.35; CI 1.15-1.58). Compared with dolutegravir, the incidence of dyslipidemia was higher with elvitegravir/cobicistat (1.20; CI 1.00-1.43) and raltegravir (1.24; CI 1.02-1.51), but lower with rilpivirine (0.77; CI 0.63-0.94).

CONCLUSION

In this large consortium of heterogeneous cohorts, dyslipidemia was less common with INSTI than with PI/b. Compared with dolutegravir, dyslipidemia was more common with elvitegravir/cobicistat and raltegravir, but less common with rilpivirine.

HIV and women in the USA: what we know and where to go from here

New diagnoses of HIV infection have decreased among women in the USA overall, but marked racial and geographical disparities persist. The federal government has announced an initiative that aims to decrease the number of new infections in the nation by 90% within the next 10 years. With this in mind, we highlight important recent developments concerning HIV epidemiology, comorbidities, treatment, and prevention among women in the USA. We conclude that, to end the US HIV epidemic, substantially greater inclusion of US women in clinical research will be required, as will better prevention and treatment efforts, with universal access to health care and other supportive services that enable women to exercise agency in their own HIV prevention and care. Ending the epidemic will also require eliminating the race, class, and gender inequities, as well as the discrimination and structural violence, that have promoted and maintained the distribution of HIV in the USA, and that will, if unchecked, continue to fuel the epidemic in the future.

Factors associated with worse cerebrovascular function in aging women with and at risk for HIV

OBJECTIVE

Women may be disproportionately impacted by the negative effect of HIV on cerebrovascular risk. We examined the association of HIV, sex, menopause, and immune activation with cerebrovascular function among women with HIV (WWH) and at risk for HIV from the Women's Interagency HIV Study and men with HIV.

DESIGN

Cross-sectional.

METHODS

Participants were aged at least 40 years with coronary heart disease or at least one cardiometabolic risk factor. All persons with HIV were on antiretroviral therapy with undetectable viral load. Cerebral vasoreactivity was assessed by the transcranial Doppler breath-holding test, with lower vasoreactivity corresponding to worse cerebrovascular function. Menopausal status was determined by anti-Müllerian hormone level. We used mixed effects linear regression to identify factors associated with cerebral vasoreactivity.

RESULTS

Mean cerebral vasoreactivity was similar in WWH (n = 33) and women at risk for HIV (n = 16). A trend toward higher cerebral vasoreactivity in WWH compared with men with HIV (n = 37) was no longer present after excluding women on estrogen replacement therapy (n = 3). In women, menopausal status was not significantly associated with cerebral vasoreactivity. WWH with higher cardiovascular risk (-0.14 for each additional cardiometabolic risk factor, P = 0.038), sCD163 (-0.20 per doubling, P = 0.033), and proportion of CD4+CX3CR1+ T cells (-0.14 per doubling, P = 0.028) had lower cerebral vasoreactivity.

CONCLUSION

Among older women at high cardiovascular risk, women with virologically suppressed HIV and women at risk for HIV had similar cerebrovascular function. Our findings, which must be interpreted in the context of the small sample, highlight the contribution of traditional cardiometabolic risk factors and immune activation to cerebrovascular risk in WWH.

Characteristics, Prevention, and Management of Cardiovascular Disease in People Living With HIV: A Scientific Statement From the American Heart Association

As early and effective antiretroviral therapy has become more widespread, HIV has transitioned from a progressive, fatal disease to a chronic, manageable disease marked by elevated risk of chronic comorbid diseases, including cardiovascular diseases (CVDs). Rates of myocardial infarction, heart failure, stroke, and other CVD manifestations, including pulmonary hypertension and sudden cardiac death, are significantly higher for people living with HIV than for uninfected control subjects, even in the setting of HIV viral suppression with effective antiretroviral therapy. These elevated risks generally persist after demographic and clinical risk factors are accounted for and may be partly attributed to chronic inflammation and immune dysregulation. Data on long-term CVD outcomes in HIV are limited by the relatively recent epidemiological transition of HIV to a chronic disease. Therefore, our understanding of CVD pathogenesis, prevention, and treatment in HIV relies on large observational studies, randomized controlled trials of HIV therapies that are underpowered to detect CVD end points, and small interventional studies examining surrogate CVD end points. The purpose of this document is to provide a thorough review of the existing evidence on HIV-associated CVD, in particular atherosclerotic CVD (including myocardial infarction and stroke) and heart failure, as well as pragmatic recommendations on how to approach CVD prevention and treatment in HIV in the absence of large-scale randomized controlled trial data. This statement is intended for clinicians caring for people with HIV, individuals living with HIV, and clinical and translational researchers interested in HIV-associated CVD.

Evolving understanding of cardiovascular, cerebrovascular and peripheral arterial disease in people living with HIV and role of novel biomarkers. A study of the Spanish CoRIS cohort, 2004-2015

Objectives

To analyze the incidence rates (IR) and spectrum of vascular events in people living with HIV (PLWH) in Spain from 2004 to 2015. Serial measurements of different plasma cardiovascular biomarkers were assessed in relation to disease development.

Methods

Longitudinal study in a nationwide contemporary multicenter cohort of PLWH. A nested case-control study was performed to evaluate the predictive value of cardiovascular biomarkers. Additive generalized and Cox mixed models were used for the analyses.

Results

9,712 PLWH and 48,341 person-years of follow-up were analysed. During 2004–2015, 147 persons developed 154 vascular events; 80 (54.42%) coronary-related; 65 (44.22%) cerebrovascular-related, and 9 (6.12%) peripheral arterial disease. The 2004–2015 IR (95% confidence interval) of vascular events was 3.17 (2.69–3.71) x1,000 person-years; 1.64 (1.30–2.05) for coronary events; 1.34 (1.03–1.70) for cerebrovascular events; and 0.19 (0.09–0.35) for peripheral arterial disease (p<0.001). IR of vascular events gradually increased from 0.37 (0.12–0.85) x1,000 patient-years in the stratum 25-34-years to 19.65 (6.38–45.85) x1,000 patient-years in the stratum 75-84-years. Compared to the general population, there was a higher incidence of acute myocardial infarction (AMI) in men (sIR ratio 1.29 [95% CI 1.16–1.42]), of cerebrovascular events in women (sIR ratio 2.44 [95% CI 1.68–3.19]), and of both types of events specifically among the younger age-strata. CD4 count (hazard ratio 0.80, [95% CI, 0.79–0.81]), age (1.86 [1.47–2.34] for 45–65 years and 3.44 [2.37–4.97] for >65 years) and vascular event (1.81 [1.12–2.94]) were associated with total mortality. Adjusted levels of intercellular-adhesion-molecule (sICAM), pro-b-type-natriuretic-peptide (pro-BNP) and marginally sCD14, were higher among patients who subsequently developed vascular events.

Conclusion

Vascular events in PLWH do preferentially occur in the older age-strata, they are associated with increased mortality and, compared to the general population, the excess risk occurs at younger ages. Peripheral arterial disease is unusual. Vascular events are preceded by increased levels of sICAM, pro-BNP and, marginally, sCD14.