Cardiovascular disease and risk assessment in people living with HIV: Current practices and novel perspectives

Characterization and stratification of risk factors of stroke in people living with HIV: A theory-informed systematic review

BACKGROUND

Identification and stratification of risk factors for stroke among individuals living with HIV (PLWH) will facilitate primary prevention and prognostication, as well as strategies aimed at optimizing neurorehabilitation. This review sought to characterize and stratify the risk factors associated with stroke in PLWH.

METHODS

The review was structured in accordance with the preferred items for reporting systematic reviews and meta-analysis (PRISMA) checklist. The epidemiological triangle, Bradford criteria, and Rothman causality model further informed the review. The review outcomes encompassed cardiovascular factors, HIV-related factors, and personal and extrinsic factors associated with stroke in PLWH. We conducted searches in PubMed, Scopus, Medline, Web of Science, Cumulative Index for Nursing and Allied Health Literature, and African Journal (SABINET). Data screening and extraction were independently performed utilizing predefined eligibility criteria and a data-extraction template. Narrative synthesis and risk stratification were employed to analyze the results.

RESULTS

Thirty studies (22 cohorts and eight case-control) with a sample size of 353,995 participants were included in this review. The mean age of the participants was 45.1 ± 10.7 years. The majority of the participants (72.4%) were male. Risk factors for stroke in PLWH include cardiovascular factors (advanced age, tobacco use, hypertension, diabetes, atrial fibrillation, etc.), HIV-related factors (high viral load and low nadir CD4 count), personal factors (advanced age and female sex), and comorbidities (hepatitis C virus infection, chronic kidney disease, coronary artery disease, and liver fibrosis or cirrhosis). Diabetes, atrial fibrillation, smoking habits, hypertension, age, and viral load demonstrated a high likelihood of association with stroke in PLWH and should be prioritized when constructing clinical prediction algorithms for HIV-related stroke.

CONCLUSIONS

The most important factors were hypertension and chronic kidney disease, followed by smoking, dyslipidemia, diabetes, HCV, HBV, CD4 count, use of ART, TB, and substance use (cocaine). The least important factors were age, sex, ethnicity, obesity, alcohol use, ART duration, and viral load. The predictive significance of these factors is still evolving, given the average moderate certainty of evidence. Predictive and preventative models should target factors with a high causality index and low investigative costs.

TRIAL REGISTRATION

The review is part of a larger review registered with the PROSPERO (ID: CRD42024524494).

Addressing Cardiometabolic Challenges in HIV: Insights, Impact, and Best Practices for Optimal Management-A Narrative Review

Introduction

Since the advent of highly active antiretroviral therapy (HAART), morbidity and mortality rates associated with human immunodeficiency virus (HIV) have significantly decreased leading to prolonged life span of Individuals living with HIV due to the effectiveness of antiretroviral therapy. However, this prolonged lifespan alone does not fully account for the increased incidence of cardiometabolic complications. These complications result from a complex interplay of factors such as chronic inflammation, immune activation, ART-related metabolic effects, and lifestyle changes. which contribute to elevated morbidity and mortality rates, therefore requiring a deeper understanding and setting effective management strategies. This review aims at providing insights and a nuanced understanding of the relationship between HIV and cardiometabolic disorders, explore their clinical implications and adapt optimal management strategies to address the multifaceted challenges at the intersection of HIV and cardiometabolic health, ultimately enhancing patient outcomes and quality of life.

Methods

Data retrieval was conducted using a predetermined search strategy from medical journals that were published in bibliographical databases like PubMed, Science Direct and Embase. This review systematically considered and synthesized current literature on the association between cardiometabolic challenges and HIV.

Results

This review provides a detailed exploration of the interrelationship between HIV and cardiometabolic challenges, with an emphasis on insights, impact, and best practices for optimal management. It underscores the high risk of cardiovascular disease, insulin resistance, dyslipidemia, and lipodystrophy in people living with HIV. Recommendations include evidence-based approaches such as routine cardiometabolic risk. Prevention, screening, management, lifestyle interventions (diet and exercise), and optimizing ART regimens to reduce the negative health outcomes experienced by people living with HIV and to direct clinical practice. To reduce health issues, enhance clinical results, and improve the long-term quality of life for people living with HIV, it is important to early identify cardiovascular risk factors and to follow customized prevention and management methods.

Conclusion

This review shows that early detection through regular screening is pivotal through collaboration between healthcare providers, researchers, and policymakers which will allow for timely interventions and drive innovation and address evolving challenges to enhancing the quality of life for individuals living with HIV. Continuing to do research and advocacy efforts, will not only advance knowledge but also optimize the long-term health outcomes for people living with HIV.

Viral intruders in the heart: A review of RNA viruses and their role in cardiac disorders

Viral cardiac diseases have a significant impact on global health, and RNA viruses play a crucial role in their pathogenesis. This literature review aims to provide a comprehensive understanding of the complex relationship between RNA viruses and cardiac diseases, focusing on the molecular processes and clinical implications of these interactions. The paper begins by discussing the various RNA viruses that have been linked to cardiac infections. Subsequently, the study explores the mechanisms through which RNA viruses can cause cardiac injury, including direct viral invasion, immune-mediated responses, and molecular mimicry. The review extensively examines the intricate interplay between the host immune system and RNA viruses, shedding light on both protective and harmful immune responses. Additionally, it investigates the role of viral persistence and chronic inflammation in the long-term effects on cardiac health. The thorough analysis presented not only enhances our scientific understanding of how RNA viruses contribute to the development of cardiac diseases but also highlights potential avenues for future research and breakthroughs in this field. Given the significant global health threat posed by viral cardiac disorders, unraveling the molecular foundations of these diseases is essential for advancing diagnostic capabilities and therapeutic interventions.

Soluble P-selectin as an inflammatory mediator potentially influencing endothelial activation in people living with HIV in sub-rural areas of Limpopo, South Africa

OBJECTIVES

There is a growing need to understand the potential role of soluble platelet selectin (sP-selectin) in sustained endothelial activation through increased levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular adhesion-1 (sVCAM-1) in people living with HIV (PLWH) on highly active antiretroviral therapy (HAART).

METHODOLOGY

This was a cross-sectional study involving PLWH on HAART (n = 55), in comparison to PLWH not on treatment (HAART-naïve) (n = 29), and (iii) HIV negative controls (n = 48) from the Mankweng area in the Limpopo province, South Africa. We quantified serum levels of sP-selectin, together with sICAM-1 and sVCAM-1. Most of the HAART-exposed group were on treatment for <5 years. We further performed frequency distribution and descriptive statistics for categorical variables.

RESULTS

Soluble P-selectin was positively correlated with sVCAM-1 (r = 0.469; p<0.001) in PLWH on HAART, even after adjusting for confounding factor such as age, BMI, and total cholesterol (r = 0.467; p<0.001). Moreover, in PLWH on HAART sP-selecting was independently associated with the release of sVCAM-1 (β = 0.445; p<0.001), even after adjusting for confounders (β = 0.475; p = 0.001). Serum levels of low-density lipoprotein cholesterol (LDL-C) (p = 0.004) and total cholesterol (p<0.001) were significantly higher in PLWH on HAART as compared to the HAART-naïve group.

CONCLUSION

There is a need for more studies to investigate the role of sP-selectin in promoting endothelial activation and CVD-risk in PLWH on HAART, especially within the sub-Saharan Africa region.

Association between the triglyceride to high-density lipoprotein cholesterol ratio and cardiovascular diseases in people living with HIV: Evidence from a retrospectively cohort study 2005-2022

INTRODUCTION

The triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio, a novel biomarker for metabolic syndrome (MetS), has been validated in the general population as being significantly correlated with cardiovascular disease (CVD) risk. However, its capabilities to predict CVD in people living with HIV (PLWH) remain underexplored.

METHODS

We conducted a retrospective cohort study of 16,081 PLWH who initiated antiretroviral therapy (ART) at the Third People's Hospital of Shenzhen (China) from 2005 to 2022. The baseline TG/HDL-C ratio was calculated as TG (mmol/L) divided by HDL-C (mmol/L). We employed a multivariate Cox proportional hazards model to assess the association between the TG/HDL-C ratio and CVD occurrence, using Kaplan-Meier curves and log-rank tests to compare survival distributions. The increase in prediction risk upon the addition of the biomarker to the conventional risk model was examined through the assessment of changes in net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Nonlinear relationships were investigated using a restricted cubic spline plot, complemented by a two-piecewise Cox proportional hazards model to analyze threshold effects.

RESULTS

At the median follow-up of 70 months, 213 PLWH developed CVD. Kaplan-Meier curves demonstrated a significant association between the increased risk of CVD and a higher TG/HDL-C ratio (log-rank P <0.001). The multivariate-adjusted Cox proportional hazards regression model indicated that the CVD hazard ratios (HR) [95% confidence intervals (95% CI)] for Q2, Q3, and Q4 versus Q1 of the TG/HDL-C ratio were 2.07 (1.24, 3.45), 2.17 (1.32, 3.57), and 2.20 (1.35, 3.58), respectively (P <0.05). The consideration of the TG/HDL-C ratio in the model, which included all significant factors for CVD incidence, improved the predictive risk, as indicated by the reclassification metrics (NRI 16.43%, 95%CI 3.35%-29.52, P = 0.014). The restriction cubic spline plot demonstrated an upward trend between the TG/HDL-C ratio and the CVD occurrence (P for non-linear association = 0.027, P for overall significance = 0.009), with the threshold at 1.013. Significantly positive correlations between the TG/HDL-C ratio and CVD were observed below the TG/HDL-C ratio threshold with HR 5.88 (95% CI 1.58, 21.88, P = 0.008), but not above the threshold with HR 1.01 (95% CI 0.88, 1.15, P = 0.880).

CONCLUSION

Our study confirms the effectiveness of the TG/HDL-C ratio as a predictor of CVD risk in PLWH, which demonstrates a significant nonlinear association. These findings indicate the potential of the TG/HDL-C ratio in facilitating early prevention and treatment strategies for CVD among PLWH.

Atherosclerosis and Cardiovascular Complications in People Living with HIV: A Focused Review

The intersection of Human Immunodeficiency Virus (HIV) infection and cardiovascular disease (CVD) represents a significant area of concern; advancements in antiretroviral therapy (ART) have notably extended the life expectancy of people living with HIV (PLWH), concurrently elevating the prevalence of chronic conditions such as CVD. This paper explores the multifaceted relationship between HIV infection, ART, and cardiovascular health, focusing on the mechanisms by which HIV and ART contribute to increased cardiovascular risk, including the promotion of endothelial dysfunction, inflammation, immune activation, and metabolic disturbances. We highlight the critical roles of HIV-associated proteins-Tat, Nef, and gp120-in accelerating atherosclerosis through direct and indirect pathways that exacerbate endothelial damage and inflammation. Additionally, we address the persistent challenge of chronic inflammation and immune activation in PLWH, factors that are strongly predictive of non-AIDS-related diseases, including CVD, even in the context of effective viral suppression. The impact of ART on cardiovascular risk is examined, with particular attention to the metabolic implications of specific ART regimens, which can influence lipid profiles and body composition, thereby modifying CVD risk. The therapeutic potential of statins, aspirin, and emerging treatments such as PCSK9 inhibitors in mitigating cardiovascular morbidity and mortality among PLWH is discussed, alongside considerations for their use in conjunction with ART. Our review underscores the necessity for a comprehensive, multidisciplinary approach to cardiovascular care in PLWH, which integrates vigilant cardiovascular risk assessment and management with HIV treatment. As we navigate the evolving landscape of HIV care, the goal remains to optimize treatment outcomes while minimizing cardiovascular risk, ensuring that the gains in longevity afforded by ART translate into improved overall health and quality of life for PLWH.

The impact of sociocultural contexts on the knowledge, attitudes, and practices of adults living with HIV/AIDS in Ethiopia towards metabolic syndrome risks: A descriptive phenomenology study using the PEN-3 model

INTRODUCTION

The global HIV/AIDS initiative in Africa aims for eradication by 2030 and treatment for 95% of HIV-positive adults by 2025. Adult People living with HIV (PLWHs) face health complications, including metabolic syndrome (MS), which heightens the risk of non-communicable diseases (NCDs) and cardiovascular problems. WHO and UNAIDS advocate for the integration of NCDs into primary healthcare, yet addressing MS remains a significant challenge in Africa. The WHO's Global Action Plan aims to reduce chronic diseases by managing risk factors and promoting healthy lifestyles within this population. However, effectively promoting healthy lifestyles necessitates an understanding of the sociocultural contexts that influence behaviors related to MS. Therefore, this study investigates how sociocultural contexts influences on knowledge, attitudes, and practices of PLWHs in Ethiopia regarding MS prevention and associated lifestyle risks, utilizing the PEN-3 model as a sociocultural framework.

METHODS

The study utilized a deductive descriptive phenomenological approach, involving 32 voluntarily selected PLWHs who sought routine care at public health institutions from December 29, 2017, to January 22, 2018. Data collection was facilitated by experienced research and task teams using standardized guidelines for focus group discussions and in-depth interviews tailored to the research context. The collected text and survey data were managed with Atlas.ti and SPSS software and analyzed through thematic content analysis. Results were reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist.

RESULTS

A study of 32 HIV-positive adults found that knowledge, attitudes, and health-related behaviors were key factors in their health. Participants learned about metabolic syndrome (MS) risks through mass media, peer discussions, and family education. However, there was a lack of awareness about the impact of HIV medications on MS and limited understanding of lifestyle factors for disease prevention. Attitudes reflect complex challenges for PLWHs in perceiving MS and its management. Health-related behaviors varied, with positive practices like fruit and vegetable consumption, regular exercise, and avoidance of harmful substances. Negative practices included sedentary lifestyles, raw meat consumption, alcohol, smoking, and 'Khat' use, which could negatively affect health outcomes. Addressing these culturally preferred behaviors is crucial for improving health among PLWHs.

CONCLUSION

The study revealed a notable knowledge gap regarding metabolic syndrome (MS) and its risk factors, leading to inadequate health attitudes and practices. Sociocultural factors-such as beliefs, values, family dynamics, and community support-are crucial in shaping the knowledge, attitudes and practice of PLWHs toward the prevention and management of chronic diseases like MS. The finding suggested that addressing the sociocultural factors affecting HIV-positive individuals' knowledge and practices regarding metabolic syndrome requires a comprehensive, inclusive approach that emphasizes education, community involvement, policy reform, and a focus on reducing stigma.

Perivascular Fat: A Novel Risk Factor for Coronary Artery Disease

Perivascular adipose tissue (PVAT) interacts with the vascular wall and secretes bioactive factors which regulate vascular wall physiology. Vice versa, vascular wall inflammation affects the adjacent PVAT via paracrine signals, which induce cachexia-type morphological changes in perivascular fat. These changes can be quantified in pericoronary adipose tissue (PCAT), as an increase in PCAT attenuation in coronary computed tomography angiography images. Fat attenuation index (FAI), a novel imaging biomarker, measures PCAT attenuation around coronary artery segments and is associated with coronary artery disease presence, progression, and plaque instability. Beyond its diagnostic capacity, PCAT attenuation can also ameliorate cardiac risk stratification, thus representing an innovative prognostic biomarker of cardiovascular disease (CVD). However, technical, biological, and anatomical factors are weakly related to PCAT attenuation and cause variation in its measurement. Thus, to integrate FAI, a research tool, into clinical practice, a medical device has been designed to provide FAI values standardized for these factors. In this review, we discuss the interplay of PVAT with the vascular wall, the diagnostic and prognostic value of PCAT attenuation, and its integration as a CVD risk marker in clinical practice.

B cells and atherosclerosis: A HIV perspective

Atherosclerosis remains a leading cause of cardiovascular disease (CVD) globally, with the complex interplay of inflammation and lipid metabolism at its core. Recent evidence suggests a role of B cells in the pathogenesis of atherosclerosis; however, this relationship remains poorly understood, particularly in the context of HIV. We review the multifaceted functions of B cells in atherosclerosis, with a specific focus on HIV. Unique to atherosclerosis is the pivotal role of natural antibodies, particularly those targeting oxidized epitopes abundant in modified lipoproteins and cellular debris. B cells can exert control over cellular immune responses within atherosclerotic arteries through antigen presentation, chemokine production, cytokine production, and cell-cell interactions, actively participating in local and systemic immune responses. We explore how HIV, characterized by chronic immune activation and dysregulation, influences B cells in the context of atherosclerosis, potentially exacerbating CVD risk in persons with HIV. By examining the proatherogenic and antiatherogenic properties of B cells, we aim to deepen our understanding of how B cells influence atherosclerotic plaque development, especially within the framework of HIV. This research provides a foundation for novel B cell-targeted interventions, with the potential to mitigate inflammation-driven cardiovascular events, offering new perspectives on CVD risk management in PLWH.

Achievement of Primary Prevention Cardiometabolic Targets in Women with HIV: An Urgent Call to Action to Pursue Cardiovascular Health

BACKGROUND

Cardiometabolic health has become crucial, especially for women with HIV (WWH). We assessed the achievement of targets for hypertension, dyslipidemia, and diabetes (H/Dy/DT) in primary prevention in a WWH cohort.

METHODS

Cross-sectional analysis including all WWH in our clinic, excluding those who had a myocardial infarction. H/Dy/DT achievement was assessed by both EACS guidelines and individual cardiovascular risk, CVR (measured by ESC calculator), using logistic regression to evaluate differences in H/Dy/DT achievement between migrant and Italian women.

RESULTS

We included 292 WWH, 55.5% Italian and 44.5% migrant women; the median age was 50 (IQR:42-58) years, 94.5% had undetectable HIV-RNA, 55.1% had a high level of education, 27.1% were smokers, and 19.2% did regularly physical exercise. Overall, 76%, 19%, and 5% of women presented a low, a high, and a very high CVR, respectively. Among Italians, 28.4% and 6.2% women presented a high and a very high CVR, respectively. Considering migrants, 7.7% and 3.8% women presented a high and a very high CVR, respectively. Overall, among migrant women, those with a high CVR were more likely to be not at target than those with a low risk (especially for LDL-c and blood pressure among people on treatment), despite the fact that we did not detect a statistically significant difference. By contrast, migrants were more likely to achieve glycemic targets than Italians (p = 0.032).

CONCLUSIONS

H/Dy/DT target achievement is suboptimal, especially in migrants. A more aggressive pharmacological treatment, also assessing adherence to medical prescriptions, and promotion of healthy lifestyle should be urgently implemented, possibly redrawing the current model of care.

Preventative Imaging with Coronary Computed Tomography Angiography

PURPOSE OF REVIEW

Coronary computed tomography angiography (CCTA) is the diagnostic modality of choice for patients with stable chest pain. In this review, we scrutinize the evidence on the use of CCTA for the screening of asymptomatic patients.

RECENT FINDINGS

Clinical evidence suggests that CCTA imaging enhances cardiovascular risk stratification and prompts the timely initiation of preventive treatment leading to reduced risk of major adverse coronary events. Visualization of coronary plaques by CCTA also helps patients to comply with preventive medications. The presence of non-obstructive plaques and total plaque burden are prognostic for cardiovascular events. High-risk plaque features and pericoronary fat attenuation index, enrich the prognostic output of CCTA on top of anatomical information by capturing information on plaque vulnerability and coronary inflammatory burden. Timely detection of atherosclerotic disease or coronary inflammation by CCTA can assist in the deployment of targeted preventive strategies and novel therapeutics to prevent cardiovascular disease.

Endothelial Glycocalyx Integrity in Treatment-Naïve People Living with HIV before and One Year after Antiretroviral Treatment Initiation

Endothelial glycocalyx (EG) derangement has been associated with cardiovascular disease (CVD). Studies on EG integrity among people living with HIV (PLWH), are lacking. We conducted a prospective cohort study among treatment-naïve PLWH who received emtricitabine/tenofovir alafenamide, combined with either an integrase strand transfer inhibitor (INSTI, dolutegravir, raltegravir or elvitegravir/cobicistat), or a protease inhibitor (PI, darunavir/cobicistat). We assessed EG at baseline, 24 (±4) and 48 (±4) weeks, by measuring the perfused boundary region (PBR, inversely proportional to EG thickness), in sublingual microvessels. In total, 66 consecutive PLWH (60 (90.9%) males) with a median age (interquartile range, IQR) of 37 (12) years, were enrolled. In total, 40(60.6%) received INSTI-based regimens. The mean (standard deviation) PBR decreased significantly from 2.17 (0.29) μm at baseline to 2.04 (0.26) μm (p = 0.019), and then to 1.93 (0.3) μm (p < 0.0001) at 24 (±4) and 48 (±4) weeks, respectively. PBR did not differ among treatment groups. PLWH on INSTIs had a significant PBR reduction at 48 (±4) weeks. Smokers and PLWH with low levels of viremia experienced the greatest PBR reduction. This study is the first to report the benefit of antiretroviral treatment on EG improvement in treatment-naïve PLWH and depicts a potential bedside biomarker and therapeutic target for CVD in PLWH.

Older PLHIV are at Higher Cardiovascular Risk with Poor Quality of Life

BACKGROUND

People with HIV (PLHIV) face increased cardiovascular disease (CVD) risk due to inflammation and immune activation. Aging further amplifies this risk. Limited data exist on CVD risk in older PLHIV in India despite 2.14 million PLHIV with higher CVD risk factors.

METHODS

In a cross-sectional study in Bihar, India, 73 PLHIV and 30 control participants were enrolled. Demographics, social factors, clinical information, and CVD risk factors were collected. HbA1c levels and lipid profiles were analyzed, and 10-year CVD risk scores were calculated using the Framingham risk score (FRS) and Qrisk3. Quality of life (QoL) was assessed using WHOQOL- HIV-BREF.

RESULTS

Results showed higher LDL levels in non-HIV older participants and higher HDL levels in younger PLHIV participants. BMI differed significantly, with higher BMI in non-HIV older individuals and lower BMI in younger PLHIV individuals. Older PLHIV participants had significantly higher mean FRS and Q-Risk scores compared to older non-PLHIV and younger PLHIV groups. Among older PLHIV participants, six had higher CVD risk per FRS, while none in the other groups were classified as high CVD risk. Psychological, social relations and spirituality domains were highly deteriorated in older PLHIV, scoring 44.48, 42.72, and 41.2, respectively. The physical domain scored 57.6, and the environment scored 52.72 in the WHOQOL-HIV bref.

CONCLUSION

In conclusion, older PLHIV in Bihar, India, face higher CVD risk compared to younger PLHIV and non-HIV individuals. FRS and Q-Risk scores effectively assessed CVD risk, identifying higher risk in older PLHIV. Age and BMI were significant predictors of high CVD risk. These findings emphasize CVD risk assessment and tailored management for older PLHIV. The QoL assessment findings indicate moderate deterioration in psychological, social relations, and spirituality domains among older PLHIV individuals. These results suggest greater challenges in psychological well-being, social interactions, and spirituality compared to the overall sample. Further research with larger samples and longitudinal designs is needed to confirm and extend these findings.

[Cardiovascular compromise in the infection by the human immunodeficiency virus]

Human immunodeficiency virus (HIV) infection was associated with increased morbidity and mortality, predominantly for opportunistic infections, before using antiretroviral therapy. With this, patients have experienced increased survival and cardiovascular compromise too. The etiology of these clinical conditions could be related to the infection itself, adverse events associated with antiretroviral therapy, or adverse events produced by the combination with other drugs. Some of these conditions have an acute onset, and their rapid recognition is vital for a better prognosis.