Riesgo cardiovascular en pacientes con infección por el virus de la inmunodeficiencia humana en España. Cohorte CoRIS, 2011

Clinical Impact of the Capacity-Motivation-Opportunity Pharmacist-Led Intervention in People Living with HIV in Spain, 2019–2020

Background

People living with HIV (PLWH) have significantly enhanced their life expectancy. Consequently, age-associated comorbidities and related health conditions are increasingly found in PLWH complicating their clinical management.

Objective

To determine the effect of the capacity-motivation-opportunity (CMO) structured pharmaceutical care intervention for improving clinical health-care results frequently associated to PLWH.

Methods

Multicenter, prospective, pre-post intervention study evaluating the CMO pharmacist-led program in adult PLWH was conducted between September 2019 and September 2020 with six months of follow-up. The primary objective of this study was to determine differences in clinical outcomes (total cholesterol, triglycerides, HDL, blood pressure and glycosylated hemoglobin) and variation in the patient’s activation measure before and after the intervention.

Results

A total of 61 patients were included, 72% were men with a median age of 53 years. After the implementation of the pharmacist-driven program, the percentage of patients with high levels of total cholesterol decreased significantly (18% to 4.9%; p < 0.001). Similarly, the prevalence of patients with high levels of triglycerides, HDL or with hypertension was significantly lower post intervention (13.1% to 6.6%, p < 0.001; 47.5% to 6.6%, p = 0.019 and 24% to 4%, p = 0.009, respectively). The number of patients who achieved the highest activation level increased from 69% to 77.6% (p < 0.001).

Conclusion

The CMO program resulted in significantly better health outcomes during the six months following the pharmacist-led intervention as well as improved activation in PLWH.

Standardized Comparison of Cardiovascular Risk Factors Prevalence in Spanish Women and Men Living with HIV and in the General Population

People living with HIV (PLWH) have an increased risk of cardiovascular (CV) disease, likely due to a higher prevalence of CV risk factors. We compared the age-standardized prevalence and management of CV risk factors in PLWH to that of the general population in Spain. Blood pressure, lipid, glucose, and anthropometric profiles were cross-sectionally compared along with the treatment of hypertension, dyslipidemia, and diabetes in a general population cohort and a PLWH cohort. Prevalence rates were standardized by the direct method by 10-year age groups in European standard populations and stratified by gender. We included 47,593 individuals aged 35 to 74 years, 28,360 from the general population cohort and 19,233 from the PLWH cohort. Compared to the general population, PLWH had a higher concentration of triglycerides (>35 mg/dL in women and >26 mg/dL in men) and a higher prevalence of smoking (>23% and >17%) and diabetes (>9.9% and >8.5%). The prevalence of treated diabetes, hypertension, and dyslipidemia were up to three-fold lower in both women and men living with HIV. There was a significant difference in PLWH compared to the general population in the lipid, glucose, and anthropometric profile. In addition, PLWH were less often treated for diagnosed diabetes, hypertension, and dyslipidemia.

Ambulatory Blood Pressure Monitoring in HIV-Infected Patients: Usefulness for Cardiovascular Risk Assessment

Background:

There is a lack of consensus regarding the risk of hypertension in HIV-infected patients compared to the general population. Ambulatory blood pressure monitoring (ABPM) is the most accurate method for the hypertension diagnosis. Nevertheless, it is rarely used in HIV clinical care.

Materials and Methods:

All HIV-infected patients who underwent 24 hours ABPM were included. The agreement between office blood pressure (BP) readings and ABPM was analyzed. The rate of patients with masked hypertension (MH), isolated clinical hypertension, and nocturnal hypertension was obtained. Furthermore, it was analyzed if the differences between both methods may affect the cardiovascular risk (CVR) assessment.

Results:

A total of 116 patients were included. The κ coefficient between office BP and ABPM was 0.248. Over a quarter of the cohort was diagnosed with MH—25.8% (CI 95% 17.7%-34.0%), and 12% (CI 95%: 6.1%-16.1%) was diagnosed with ICH. Moreover, 19% of patients had hypertension exclusively during the night. The patients classified as low risk according to the CVR scores had a different diagnosis with ABPM than with office BP (P < .001).

Conclusions:

The agreement between office BP and ABPM was low in HIV-infected patients. Ambulatory BP monitoring is useful in HIV-infected patients as a hypertension diagnosis method, especially among patients classified as low risk.

Cardiovascular risk in HIV-infected individuals: A comparison of three risk prediction algorithms

INTRODUCTION

Cardiovascular (CV) risk is known to be increased in HIV-infected individuals. Our aim was to assess CV risk in HIV-infected adults.

METHODS

CV risk was estimated for each patient using three different risk algorithms: SCORE, the Framingham risk score (FRS), and DAD. Patients were classified as at low, moderate or high CV risk. Clinical and anthropometric data were collected.

RESULTS

We included 571 HIV-infected individuals, mostly male (67.1%; n=383). Patients were divided into two groups according to antiretroviral therapy (ART): naïve (7.5%; n=43) or under ART (92.5%; n=528). The mean time since HIV diagnosis was 6.7±6.5 years in the naive group and 13.3±6.1 years in the ART group. Metabolic syndrome (MS) was identified in 33.9% (n=179) and 16.3% (n=7) of participants in the ART and naïve groups, respectively. MS was associated with ART (OR=2.7; p=0.018). Triglycerides ≥150 mg/dl (OR=13.643, p<0.001) was one of the major factors contributing to MS. Overall, high CV risk was found in 4.4% (n=23) of patients when the SCORE tool was used, in 20.5% (n=117) using the FRS, and in 10.3% (n=59) using the DAD score. The observed agreement between the FRS and SCORE was 55.4% (k=0.183, p<0.001), between the FRS and DAD 70.5% (k=0.465, p<0.001), and between SCORE and DAD 72.3% (k=0.347, p<0.001).

CONCLUSION

On the basis of the three algorithms, we detected a high rate of high CV risk, particularly in patients under ART. The FRS was the algorithm that classified most patients in the high CV risk category (20.5%). In addition, a high prevalence of MS was identified in this patient group.

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.

Risk of cancer in HIV-infected patients in Spain, 2004-2015. The CoRIS cohort study

INTRODUCTION

Cancer is a leading cause of death in individuals with HIV.

METHODS

The incidence of cancer in HIV patients of the CoRIS cohort in the 2004-2009 and 2010-2015 periods has been analysed and compared to the incidence in the Spanish general population, estimated from data of the Spanish Cancer Registry Network.

RESULTS

Between January 2004 and November 2015, 12,239 patients were included in CoRIS and 338 incident cancer cases were diagnosed. The overall incidence of cancer per 100,000 persons-year (95% CI) was 702.39 (629.51-781.42) with no significant differences between the 2periods. A 38% of the incident cancer cases were AIDS defining cancers (ADC) and 62% non-AIDS defining cancers (NADC). In the period 2010-2015, there was a significant decrease in the incidence of ADC (standardised incidence ratio [SIR]); 95% CI: 0.38; 0.21-0.66) and NADC predominated. Compared to the general population, the incidence of cancer was double in men with HIV. Higher relative risks were documented (SIR; 95% CI) for Hodgkin's lymphoma in both sexes (males: 8.37, 5.13-14.17; females: 21.83, 2.66-47.79), non-Hodgkin's lymphoma in males (5.30, 2.86-8.45) and cervical cancer (7.43, 3.15-13.87) and head and neck cancer (3.28, 1.21-5.82) in women.

CONCLUSIONS

The overall incidence of cancer in individuals with HIV is higher than in the Spanish general population, and it has remained stable since 2004 with a current predominance of NADC. These data suggest that additional efforts should be made in the prevention and the early detection of cancer in these patients.

T cell senescence predicts subclinical atherosclerosis in HIV-infected patients similarly to traditional cardiovascular risk factors

The main objective of this study is to evaluate the predictive capacity of T cell activation/senescence in subclinical atherosclerosis (SCA) in a group of HIV-infected patients. So, a cross-sectional analysis was performed on 91 long-term triple-ART therapy HIV-infected patients from an observational and prospective cohort. Carotid Intima Media Thickness (cIMT) was measured. Binary logistic regression was used to evaluate independent variables associated with SCA. Compared to patients without SCA, patients with SCA (60.4%) were older (41.33 ± 9.04 vs. 51.73 ± 8.44 years old, p < 0.001) and showed Framingham risk score (2.63 ± 3.127 vs. 7.66 ± 5.84, p = 0.008), as well as higher numbers of CD4⁺CD8⁺ double positive T cells (0.50 ± 0.42% vs. 0.81 ± 0.79%, p = 0.037), CD8⁺CD28^- T cells (41.70 ± 16.96% vs. 50.22 ± 16.15%, p = 0.018), higher expression of CD28 on CD8⁺CD28⁺ T cells (1865 ± 789 vs. 2243 ± 917 MFI, P = 0.046). In contrast, they showed lower expression of CD38 on CD19⁺ B cells (65.38 ± 27.47% vs. 42.67 ± 30.26%, P < 0.001). Logistic multivariable analysis showed that Framingham risk score >10% (OR = 14.84, CI95% 1.63-125; p = 0.016) and numbers of CD8⁺CD28^- T cells (OR = 1.032, CI 95% 1-1.065; p = 0.045) were independent factors associated with SCA. Patients with CD8⁺CD28^- T cells ≥59% compared to those <59% had higher risk of SCA (OR = 4, CI95% 1.19-13.3, p = 0.024). Interestingly, 27.4% of patients with low Framingham risk score had elevated levels of CD8⁺CD28^- T cells. In conclusion, immune senescence represented by accumulation of CD8⁺CD28^- T cells may contribute to improve the predictive capacity of the Framingham risk score, especially when the scores are low and can explain, at least in part, the higher prevalence of SCA observed in long-term ART-treated stable HIV infected patients.

Effect of a Structured Pharmaceutical Care Intervention Versus Usual Care on Cardiovascular Risk in HIV Patients on Antiretroviral Therapy: INFAMERICA Study

BACKGROUND

HIV+ patients have increased their life expectancy with a parallel increase in age-associated comorbidities.

OBJECTIVE

To determine the effectiveness of an intensive pharmaceutical care follow-up program in comparison to a traditional model among HIV-infected patients with moderate/high cardiovascular risk.

METHOD

This was a multicenter, prospective, randomized study of a structured health intervention conducted between January-2014 and June-2015 with 12 months of follow-up at outpatient pharmacy services. The selected patients were randomized to a control group (usual care) or intervention group (intensive pharmaceutical care). The interventional program included follow-up of all medication taken by the patient to detect and work toward the achievement of pharmacotherapeutic objectives related to cardiovascular risk and making recommendations for improving diet, exercising, and smoking cessation. Individual motivational interview and periodic contact by text messages about health promotion were used. The primary end point was the percentage of patients who had reduced the cardiovascular risk index, according to the Framingham-score.

RESULTS

A total of 53 patients were included. As regards the main variable, 20.7% of patients reduced their Framingham-score from high/very high to moderate/low cardiovascular risk versus 12.5% in the control group ( P=0.016). In the intervention group, the number of patients with controlled blood pressure increased by 32.1% ( P=0.012); 37.9% of patients overall stopped smoking ( P=0.001), and concomitant medication adherence increased by 39.4% at the 48-week follow-up ( P=0.002). Conclusion and Relevance: Tailored pharmaceutical care based on risk stratification, motivational interviewing, and new technologies might lead to improved health outcomes in HIV+ patients at greater cardiovascular risk.

Decreasing rates of acute myocardial infarction in people living with HIV: a nationwide cohort study in Spain, 2004-2015

OBJECTIVES

Contemporary data from country-wide cohorts are needed to reveal trends in the occurrence of acute myocardial infarction (AMI) in people living with HIV (PLWH). We analysed time trends in the standardized incidence rate (sIR) of AMI in PLWH in Spain from 2004 to 2015, and compared them with trends in the general population.

METHODS

A longitudinal study in a nationwide contemporary multicentre HIV-infected cohort was carried out. Data on all incident AMI events were collected, and age- and sex-standardized IRs calculated. To analyse the IR of AMI in the general population, the national rates of hospital discharges for AMI per 100 000 inhabitants stratified for age and sex from 2004 to 2015 were obtained using the morbidity report data from the National Statistics Institute. A Poisson regression model was fitted to assess the effect of covariates of interest on AMI occurrence.

RESULTS

The sIRs of AMI in 2004-2015 were 237.92 [95% confidence interval (CI) 225.95-249.90] and 66.75 (95% CI: 23.49-110.01) per 100 000 patient-years in male and female PLWH, respectively. There was a decrease in the sIR of AMI in male PLWH from 279.02 (95% CI: 265.46-292.59) per 100 000 person-years in 2004-2009 to 222.13 (95% CI: 210.83-233.42) per 100 000 person-years in 2010-2015. Compared with the general population, the sIR ratio was 1.41 (95% CI: 1.26-1.55) in 2004-2009, and 1.28 (95% CI: 1.15-1.43) in 2010-2014. AMI occurrence was associated with older age (P < 0.066 for each 10-year age stratum ≥ 35-years compared with the 25-34 year stratum), higher plasma HIV RNA (P < 0.001), lower CD4 count (P < 0.04 for CD4 strata > 350 cells/μL compared with the 0-100 cells/μL stratum), and the period 2004-2009 (P < 0.001).

CONCLUSIONS

There has been a decreasing incidence of AMI in PLWH in Spain, associated with improving immune and virological status, but the incidence of AMI has remained higher than in the general population.

Impact of pharmaceutical care on cardiovascular risk among older HIV patients on antiretroviral therapy

Background Advances in the treatment of HIV infection have enabled better control of the disease, allowing patients to enjoy a longer life expectancy. However, the ageing of patients leads to an increased prevalence of cardiovascular disease. Various studies have found that pharmaceutical care results in better control of cardiovascular risk factors. Objective To measure the impact of pharmaceutical care on cardiovascular risk in patients older than 50 years receiving combination antiretroviral therapy. Setting Outpatient pharmacy service of a tertiary hospital, Spain. Methods A pre/post-intervention quasi-experimental clinical study was conducted in which health education and pharmacist interventions to reduce cardiovascular risk factors were carried out in a single patient cohort using the Dader method of pharmacotherapy, with a 12-month follow-up period per patient. Patients included were older than 50 years, with moderate/elevated cardiovascular risk. Data were obtained from patient clinical histories, dispensing records and patient interviews, and were subjected to statistical analysis. Main outcome measure Cardiovascular risk estimated by SCORE and REGICOR equations. Results Forty-two patients completed the study. Of these, 93 % were men, with an average age of 57 years and 15 years since diagnosis of HIV. A reduction was observed in the mean values (baseline vs. 12 months) of the following cardiovascular risk factors: systolic blood pressure (P = 0.009), diastolic blood pressure (P = 0.010), total cholesterol (P = 0.006), low-density lipoprotein cholesterol (LDL-c; P = 0.039), triglycerides (P = 0.010) and total cholesterol/high-density lipoprotein cholesterol (HDL-c; P < 0.001). An increase in HDL-c (P = 0.037) was also observed. The average cardiovascular risk estimated by the SCORE instrument was reduced from 7.6 % at the beginning of the study to 6.4 % after 12 months (P = 0.039). The risk estimate according to REGICOR also decreased (P = 0.002). Over the 12-month period, 6.3 ± 3.4 interventions were carried out per patient. Quantitative ineffectiveness was the most prevalent negative outcome associated with medication throughout the study, and noncompliance was the most frequent cause. Interventions on health education were the most common, followed by interventions on improving adherence. Conclusion Pharmaceutical care, delivered as a combination of health education and pharmacotherapy follow-up to outpatients at a tertiary hospital, had a positive impact on cardiovascular risk in patients older than 50 years receiving combination antiretroviral therapy.

Recreational drug use among individuals living with HIV in Europe: review of the prevalence, comparison with the general population and HIV guidelines recommendations

Background: Adherence problems, interactions and higher rate of risk activities have been observed in HIV individuals using recreational drugs. Our aim was to describe recreational drug use in both HIV individuals and general population in Europe, and to assess at what extent HIV guidelines address this issue.

Methods: Data on recreational drug use across Europe were obtained from the European Monitoring Centre for Drugs and Drug Addiction for the general population, and through Pubmed search. for HIV patients. We assessed the incorporation of recreational drug issues in HIV treatment guidelines for the following topics: (a) recreational drugs; (b) adherence to antiretrovirals; (c) interactions; (d) transmission risk. Guidelines included: World Health Organization; European Aids Clinical Society; U.S. Department of Health and Human Services; International Antiviral Society-USA; and seven European national guidelines.

Results: 29 countries reported recreational drug use in general population. The highest prevalences were observed for Cannabis (i.e., 8–10% in Spain, France, and Czech Republic) followed by cocaine, amphetamines and ecstasy. The 13 studies selected in the systematic review showed a great variability in recreational drug use on the HIV population. Apart from classical recreational drugs, we found a relevant use of new drugs including sexual experience enhancers. Polydrug consumption was about 50% in some studies. Most guidelines included general information about recreational drugs, showing great variability on the inclusion of the evaluated topics. We found more specific, evidence-based recommendations on interactions, followed by medication adherence and transmission risk.

Conclusions: Available data on the people living with HIV suggest a higher use of recreational drugs than in the general population, which is already relevant. However, recreational drug issues should be included or addressed more thoroughly in most guidelines.

[Deaths due to non-AIDS diseases among HIV infected patients: A 14-year study (1998-2011)]

BACKGROUND AND OBJECTIVE

The objective of this study was to analyze the deaths caused by non-AIDS diseases in a cohort of HIV-infected patients treated between 1998 and 2011.

PATIENTS AND METHODS

Information on the causes of death was collected retrospectively, and then classified according to the deaths code (CoDe) algorithm. Patient characteristics and causes of death were compared for two periods: 1998-2004 and 2005-2011.

RESULTS

A total of 159 out of the 1070 patients cared for in study period died, 56 (35%) due to AIDS events and 86 (54%) due to non-AIDS events (NAEs); in 17 (11%) the cause of death could not be determined. Overall, the main causes of death were infections (32%), cancer (17%), and unnatural deaths (17%). There was lower mortality from AIDS-related conditions during the second period (18.5% vs 47%; P<.001) and higher mortality from NAEs (68% vs 45%; P=.006). There was a very sharp increase in non-AIDS-defining cancers (18.5% vs 2.1%, p=001), and increased deaths from cardiovascular disease (9.2% vs 2.1%, P=.06). Patients who died in the second period were older, and had a better immunological and virological status at cohort entry and before death. They received antiretroviral therapy (ART) more often and were more often virologically suppressed before death (61.5% vs 24%; P=.001).

CONCLUSIONS

Non-AIDS-defining cancers, unnatural deaths, and cardiovascular diseases are now major causes of death in patients with HIV. In recent years the majority of deceased patients are on ART and with virological suppression.

Traditional risk factors are more relevant than HIV-specific ones for carotid intima-media thickness (cIMT) in a Brazilian cohort of HIV-infected patients

Background

Combination antiretroviral therapy (cART) had a dramatic impact on the mortality profile in human immunodeficiency virus (HIV) infected individuals and increased their life-expectancy. Conditions associated with the aging process have been diagnosed more frequently among HIV-infected patients, particularly, cardiovascular diseases.

Methods

Patients followed in the Instituto de Pesquisa Clínica Evandro Chagas (IPEC) prospective cohort in Rio de Janeiro were submitted to the general procedures from the Brazilian Longitudinal Study of Adult Health, comprising several anthropometric, laboratory and imaging data. Carotid intima-media thickness (cIMT) was measured by ultrasonography, following the Mannheim protocol. Linear regression and proportional odds models were used to compare groups and covariables in respect to cIMT. The best model was chosen with the adaptive lasso procedure.

Results

A valid cIMT exam was available for 591 patients. Median cIMT was significantly larger for men than women (0.56mm vs. 0.53mm; p = 0.002; overall = 0.54mm). In univariable linear regression analysis, both traditional risk factors for cardiovascular diseases (CVD) and HIV-specific characteristics were significantly associated with cIMT values, but the best multivariable model chosen included only traditional characteristics. Hypertension presented the strongest association with higher cIMT terciles (OR = 2.51; 95%CI = 1.69–3.73), followed by current smoking (OR = 1,82; 95%CI = 1.19–2.79), family history of acute myocardial infarction or stroke (OR = 1.60; 95%CI = 1.10–2.32) and age (OR per year = 1.12; 95%CI = 1.10–1.14).

Conclusions

Our results show that traditional cardiovascular disease (CVD) risk factors are the major players in determining increased cIMT among HIV infected patients in Brazil. This finding reinforces the need for thorough assessment of those risk factors in these patients to guarantee the incidence of CVD events remain under control.

Cardiovascular risk factors and lifetime risk estimation in HIV-infected patients under antiretroviral treatment in Spain

BACKGROUND AND OBJECTIVES

Cardiovascular disease is a major concern in HIV-infected patients. Lifetime risk estimations use the risk of developing it over the course of remaining lifetime, and are useful in communicating this risk to young patients. We aim to describe the prevalence of cardiovascular risk factors among a representative sample of HIV-infected subjects under antiretroviral therapy in Spain, and to estimate their lifetime risk of cardiovascular disease.

METHODS

Cross-sectional survey about cardiovascular risk factors in 10 HIV units across Spain. Lifetime risk assessed according to Barry was classified in two major categories: low and high lifetime risk.

RESULTS

We included 895 subjects, 72% men, median age 45.7 years; median CD4 lymphocyte count 598 cells/μl, median time since HIV diagnosis 11 years, median time on antiretroviral treatment 6.3 years, 87% had undetectable HIV viral load. Tobacco smoking was the most frequent risk factor (54%), followed by dyslipidemia (48.6%) and hypertension (38.6%). Estimated 10-year coronary risk (Framingham/Regicor Risk Score) risk was low ( < 5%) in 78% of the patients, and intermediate (5-10%) in 20%. Lifetime risk estimation showed a high risk profile for 71.4% of the population studied, which was associated with increasing age, prolonged antiretroviral therapy and patient's place of origin.

CONCLUSIONS

Modifiable cardiovascular risk factors in this population are very common. There are significant disparities between the low 10-year risk estimated with the Framingham/Regicor score and the higher lifetime risk in HIV patients on antiretroviral therapy. A more aggressive management of modifiable cardiovascular risk factors in these patients seems advisable.

Influence of immune activation and inflammatory response on cardiovascular risk associated with the human immunodeficiency virus

Patients infected with the human immunodeficiency virus (HIV) have an increased cardiovascular risk. Although initially this increased risk was attributed to metabolic alterations associated with antiretroviral treatment, in recent years, the attention has been focused on the HIV disease itself. Inflammation, immune system activation, and endothelial dysfunction facilitated by HIV infection have been identified as key factors in the development and progression of atherosclerosis. In this review, we describe the epidemiology and pathogenesis of cardiovascular disease in patients with HIV infection and summarize the latest knowledge on the relationship between traditional and novel inflammatory, immune activation, and endothelial dysfunction biomarkers on the cardiovascular risk associated with HIV infection.

[Peripheral arterial disease and cardiovascular risk factors among patients infected with human immunodeficiency virus: a comparison between hospital out-patients and patients in a prison]

INTRODUCTION

Cardiovascular disease among human immunodeficiency virus (HIV) infected patients is more frequent than in the general population. Peripheral arterial disease measured by ankle-brachial index (ABI) and cardiovascular risk factors (CVRF) is not well known in all groups of HIV-infected patients.

METHODS

Transversal study of HIV-infected patients >45 years, seen as outpatients in hospital (HO) in 2008 and patients institutionalized in a prison in 2009. Cardiovascular risk factors, information on the HIV infection and healthy lifestyles were evaluated. ABI was measured at rest and was considered pathological when a value ≤ 0.9 or ≥ 1.3 was obtained.

RESULTS

We included 71 patients (mean age of 50.6 ± 6.9 years, 86% male), 32 HO and 39 in prison. The most prevalent CVRF was smoking (80.2%) followed by an altered lipid profile (63.3%). The evolution time of HIV infection was 13.1 ± 7.1 years. 74.6% of patients didn't follow a heart-healthy diet and 25% were sedentary. The ABI was low in 7 cases (9.8%) and ≥ 1.3 in one. Patients in prison were younger, the rate of smokers and of individuals with low HDL were higher, the time of evolution of the HIV infections was longer and they were less adherent to a heart-healthy diet than in HO, reaching in all cases statistical significance (P<.05).

CONCLUSIONS

In our study there is a high prevalence of altered ABI. The most common CVRF is smoking, followed by the alteration of lipids. Patients in prison are more likely to be smokers, to have low HDL and they are less adherence to a heart-healthy diet.

[Consensus Statement by GeSIDA/National AIDS Plan Secretariat on antiretroviral treatment in adults infected by the human immunodeficiency virus (Updated January 2013)]

OBJECTIVE

This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients.

METHODS

To formulate these recommendations a panel composed of members of the GeSIDA/National AIDS Plan Secretariat (Grupo de Estudio de Sida and the Secretaría del Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations and the evidence which support them are based on a modification of the criteria of Infectious Diseases Society of America.

RESULTS

cART is recommended in patients with symptoms of HIV infection, in pregnant women, in serodiscordant couples with high risk of transmission, in hepatitisB co-infection requiring treatment, and in HIV nephropathy. cART is recommended in asymptomatic patients if CD4 is <500cells/μl. If CD4 are >500cells/μl cART should be considered in the case of chronic hepatitisC, cirrhosis, high cardiovascular risk, plasma viral load >100.000 copies/ml, proportion of CD4 cells <14%, neurocognitive deficits, and in people aged >55years. The objective of cART is to achieve an undetectable viral load. The first cART should include 2 reverse transcriptase inhibitors (RTI) nucleoside analogs and a third drug (a non-analog RTI, a ritonavir boosted protease inhibitor, or an integrase inhibitor). The panel has consensually selected some drug combinations, for the first cART and specific criteria for cART in acute HIV infection, in tuberculosis and other HIV related opportunistic infections, for the women and in pregnancy, in hepatitisB or C co-infection, in HIV-2 infection, and in post-exposure prophylaxis.

CONCLUSIONS

These new guidelines update previous recommendations related to first cART (when to begin and what drugs should be used), how to monitor, and what to do in case of viral failure or adverse drug reactions. cART specific criteria in comorbid patients and special situations are similarly updated.