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Obare LM, Temu T, Mallal SA, Wanjalla CN. Inflammation in HIV and Its Impact on Atherosclerotic Cardiovascular Disease. Circ Res 2024; 134:1515-1545. [PMID: 38781301 PMCID: PMC11122788 DOI: 10.1161/circresaha.124.323891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
People living with HIV have a 1.5- to 2-fold increased risk of developing cardiovascular disease. Despite treatment with highly effective antiretroviral therapy, people living with HIV have chronic inflammation that makes them susceptible to multiple comorbidities. Several factors, including the HIV reservoir, coinfections, clonal hematopoiesis of indeterminate potential (CHIP), microbial translocation, and antiretroviral therapy, may contribute to the chronic state of inflammation. Within the innate immune system, macrophages harbor latent HIV and are among the prominent immune cells present in atheroma during the progression of atherosclerosis. They secrete inflammatory cytokines such as IL (interleukin)-6 and tumor necrosis-α that stimulate the expression of adhesion molecules on the endothelium. This leads to the recruitment of other immune cells, including cluster of differentiation (CD)8+ and CD4+ T cells, also present in early and late atheroma. As such, cells of the innate and adaptive immune systems contribute to both systemic inflammation and vascular inflammation. On a molecular level, HIV-1 primes the NLRP3 (NLR family pyrin domain containing 3) inflammasome, leading to an increased expression of IL-1β, which is important for cardiovascular outcomes. Moreover, activation of TLRs (toll-like receptors) by HIV, gut microbes, and substance abuse further activates the NLRP3 inflammasome pathway. Finally, HIV proteins such as Nef (negative regulatory factor) can inhibit cholesterol efflux in monocytes and macrophages through direct action on the cholesterol transporter ABCA1 (ATP-binding cassette transporter A1), which promotes the formation of foam cells and the progression of atherosclerotic plaque. Here, we summarize the stages of atherosclerosis in the context of HIV, highlighting the effects of HIV, coinfections, and antiretroviral therapy on cells of the innate and adaptive immune system and describe current and future interventions to reduce residual inflammation and improve cardiovascular outcomes among people living with HIV.
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Affiliation(s)
- Laventa M. Obare
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN (L.M.O., S.A.M., C.N.W.)
| | - Tecla Temu
- Department of Pathology, Harvard Medical School, Boston, MA (T.T.)
| | - Simon A. Mallal
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN (L.M.O., S.A.M., C.N.W.)
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN (S.A.M.)
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN (S.A.M.)
- Institute for Immunology and Infectious Diseases, Murdoch University, WA, Western Australia (S.A.M.)
| | - Celestine N. Wanjalla
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN (L.M.O., S.A.M., C.N.W.)
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Haji M, Capilupi M, Kwok M, Ibrahim N, Bloomfield GS, Longenecker CT, Rodriguez-Barradas MC, Ashong CN, Jutkowitz E, Taveira TH, Richard M, Sullivan JL, Rudolph JL, Wu WC, Erqou S. Clinical Outcomes After Acute Coronary Syndromes or Revascularization Among People Living With HIV: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2411159. [PMID: 38743421 PMCID: PMC11094563 DOI: 10.1001/jamanetworkopen.2024.11159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/07/2024] [Indexed: 05/16/2024] Open
Abstract
Importance Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. Objective To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Data Sources Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Study Selection Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data Extraction and Synthesis Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. Main Outcome and Measures The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. Results A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and β-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). Conclusions and Relevance These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.
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Affiliation(s)
- Mohammed Haji
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael Capilupi
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael Kwok
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nouran Ibrahim
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Gerald S. Bloomfield
- Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Maria C. Rodriguez-Barradas
- Infectious Disease Section, Michael E. DeBakey VA Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Chester N. Ashong
- Pharmacy Service, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Eric Jutkowitz
- Center of Innovation, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center, Providence VA Health Care System, Providence, Rhode Island
| | - Tracey H. Taveira
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
- Department of Pharmacy, University of Rhode Island, Providence
| | - Michelle Richard
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
| | - Jennifer L. Sullivan
- Center of Innovation, Providence VA Medical Center, Providence, Rhode Island
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - James L. Rudolph
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
- Center of Innovation, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center, Providence VA Health Care System, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
| | - Wen-Chih Wu
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
- Center of Innovation, Providence VA Medical Center, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
| | - Sebhat Erqou
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
- Center of Innovation, Providence VA Medical Center, Providence, Rhode Island
- Evidence Synthesis Program Center, Providence VA Health Care System, Providence, Rhode Island
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island
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Althoff KN, Stewart C, Humes E, Gerace L, Boyd C, Gebo K, Justice AC, Hyle EP, Coburn SB, Lang R, Silverberg MJ, Horberg MA, Lima VD, Gill MJ, Karris M, Rebeiro PF, Thorne J, Rich AJ, Crane H, Kitahata M, Rubtsova A, Wong C, Leng S, Marconi VC, D’Souza G, Kim HN, Napravnik S, McGinnis K, Kirk GD, Sterling TR, Moore RD, Kasaie P. The forecasted prevalence of comorbidities and multimorbidity in people with HIV in the United States through the year 2030: A modeling study. PLoS Med 2024; 21:e1004325. [PMID: 38215160 PMCID: PMC10833859 DOI: 10.1371/journal.pmed.1004325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/01/2024] [Accepted: 11/22/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Estimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. The objective of our study was to forecast the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the United States (US) through 2030. METHODS AND FINDINGS Using the PEARL model-an agent-based simulation of PWH who have initiated ART in the US-the prevalence of anxiety, depression, stage ≥3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity (≥2 mental or physical comorbidities, other than HIV) were forecasted through 2030. Simulations were informed by the US CDC HIV surveillance data of new HIV diagnosis and the longitudinal North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data on risk of comorbidities from 2009 to 2017. The simulated population represented 15 subgroups of PWH including Hispanic, non-Hispanic White (White), and non-Hispanic Black/African American (Black/AA) men who have sex with men (MSM), men and women with history of injection drug use and heterosexual men and women. Simulations were replicated for 200 runs and forecasted outcomes are presented as median values (95% uncertainty ranges are presented in the Supporting information). In 2020, PEARL forecasted a median population of 670,000 individuals receiving ART in the US, of whom 9% men and 4% women with history of injection drug use, 60% MSM, 8% heterosexual men, and 19% heterosexual women. Additionally, 44% were Black/AA, 32% White, and 23% Hispanic. Along with a gradual rise in population size of PWH receiving ART-reaching 908,000 individuals by 2030-PEARL forecasted a surge in prevalence of most comorbidities to 2030. Depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension decreased while dyslipidemia, diabetes, CKD, and MI increased. There was little change in prevalence of cancer and ESLD. The forecasted multimorbidity among PWH receiving ART increased from 63% in 2020 to 70% in 2030. There was heterogeneity in trends across subgroups. Among Black women with history of injection drug use in 2030 (oldest demographic subgroup with median age of 66 year), dyslipidemia, CKD, hypertension, diabetes, anxiety, and depression were most prevalent, with 92% experiencing multimorbidity. Among Black MSM in 2030 (youngest demographic subgroup with median age of 42 year), depression and CKD were highly prevalent, with 57% experiencing multimorbidity. These results are limited by the assumption that trends in new HIV diagnoses, mortality, and comorbidity risk observed in 2009 to 2017 will persist through 2030; influences occurring outside this period are not accounted for in the forecasts. CONCLUSIONS The PEARL forecasts suggest a continued rise in comorbidity and multimorbidity prevalence to 2030, marked by heterogeneities across race/ethnicity, gender, and HIV acquisition risk subgroups. HIV clinicians must stay current on the ever-changing comorbidities-specific guidelines to provide guideline-recommended care. HIV clinical directors should ensure linkages to subspecialty care within the clinic or by referral. HIV policy decision-makers must allocate resources and support extended clinical capacity to meet the healthcare needs of people aging with HIV.
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Affiliation(s)
- Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Cameron Stewart
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth Humes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lucas Gerace
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Cynthia Boyd
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kelly Gebo
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Amy C. Justice
- Yale Schools of Medicine and Public Health, New Haven, Connecticut, United States of America
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States of America
| | - Emily P. Hyle
- Harvard Medical School and the Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Boston, Massachusetts, United States of America
| | - Sally B. Coburn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Raynell Lang
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Michael J. Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA and Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland, United States of America
| | - Viviane D. Lima
- Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - M. John Gill
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Maile Karris
- Department of Medicine, University of California San Diego, San Diego, California, United States of America
| | - Peter F. Rebeiro
- Departments of Medicine and Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Jennifer Thorne
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Ashleigh J. Rich
- Department of Social Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Heidi Crane
- Division of Allergy and Infectious Diseases, Departments of Medicine and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Mari Kitahata
- Division of Allergy and Infectious Diseases, Departments of Medicine and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Anna Rubtsova
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Cherise Wong
- Division of Worldwide Research and Development, Pfizer Inc., New York City, New York, United States of America
| | - Sean Leng
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Vincent C. Marconi
- Division of Infectious Disease, Emory School of Medicine, Atlanta, Georgia, United States of America
- Atlanta Veterans Affairs Health Care System, Decatur, Georgia, United States of America
| | - Gypsyamber D’Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Hyang Nina Kim
- Division of Allergy and Infectious Diseases, Departments of Medicine and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Kathleen McGinnis
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States of America
| | - Gregory D. Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Timothy R. Sterling
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Richard D. Moore
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Parastu Kasaie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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