Differences between HIV-infected and uninfected adults in the contributions of smoking, diabetes and hypertension to acute coronary syndrome: two parallel case-control studies

Optimizing behavioral and pharmacological smoking cessation interventions among people with HIV

BACKGROUND

People with HIV/AIDS (PWH) smoke at nearly three times the rate of the general population. Interventions to promote sustained quitting among PWH are urgently needed.

METHODS

Our study used a randomized factorial design to evaluate the effects of varenicline, compared with placebo, and behavioral cessation therapy, positively smoke free (PSF), compared with standard of care (SOC) among PWH who smoke. The study was designed with power to detect a small effect (Cohen's h of 0.28-0.36) with 240 participants. The primary outcome was the 7-day point prevalence abstinence (PPA) confirmed by exhaled carbon monoxide (ECO) less than 10 ppm for both main effects at 36 weeks. The study was conducted from June 2016 to November 2020. During the study's last year, recruitment was halted because of COVID-19.

RESULTS

The study randomized 184 participants with power to detect a medium effect (Cohen's h of 0.41). Participants were mostly African American (89.7%), men (62.8%) who smoked mentholated cigarettes (96.7%). Nearly all received antiretroviral medication (96.2%). Quit rates for the entire sample were 7.5% at 36 weeks. Compared with those who received placebo, neither those who received varenicline [36 weeks; OR (95% CI), 1.31 (0.33-5.22), P  = 0.70] nor PSF [36 weeks; OR (95% CI), 0.26 (0.03-2.44), P  = 0.24) were more likely to quit smoking.

CONCLUSION

Among an urban living, primarily African American sample of PWH who smoke neither varenicline nor PSF was found to be efficacious at 36 weeks. Our study was not powered to detect small effects sizes. Larger trials are needed to establish tobacco treatment standards for PWH who smoke.

High Concordance between D:A:Dr and the Framingham Risk Score in Brazilians Living with HIV

People living with HIV (PLHIV) have twice the risk of developing cardiovascular diseases, making it essential to identify high cardiovascular risk (CVR). However, there is no validated CVR calculator for PLHIV in Brazil. We performed a cross-sectional study with 265 individuals living with HIV, aged 40 to 74 years, to assess the agreement between three CVR scores: Framingham Risk Score (FRS), Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score, and a specific for PLHIV, Reduced Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:Dr). We assessed agreement using the weighted Kappa coefficient and the Bland-Altman plot. The median age was 52 years (47-58), 58.9% were men, 34% were hypertensive and 8.3% had a detectable viral load. There was an almost perfect agreement between D:A:Dr x FRS (k = 0.82; 95% CI 0.77-0.87; p < 0.001), and substantial agreement between FRS vs. ASCVD (k = 0.74; 95% CI 0.69-0.79; p < 0.001) and between D:A:Dr vs. ASCVD (k = 0.70; 95% CI 0.64-0.76; p < 0.001). The Bland-Altman plot revealed greater discordance between scores as the CVR increased. Our results suggest that the FRS and the D:A:Dr are adequate to classify the CVR in this population, and the D:A:Dr score can be used as an alternative to the FRS in Brazil, as other international guidelines have already advocated.

Addressing gaps in cardiovascular care for people with HIV: bridging scientific evidence and practice

PURPOSE OF REVIEW

People with HIV continue to have an excess burden of cardiovascular disease compared to the general population. The reasons for these disparities in cardiovascular disease include HIV-specific risk enhancers, traditional atherosclerotic cardiovascular disease risk factors, and sociodemographic disparities, all of which are ripe targets for intervention.

RECENT FINDINGS

Accurate risk prediction of atherosclerotic cardiovascular disease remains difficult, and cardiovascular risk for people with HIV may be underestimated in the absence of HIV-specific risk enhancers. Despite this increased cardiovascular risk, people with HIV are undertreated and often placed on inadequate lipid lowering therapy. Structural racism and HIV-related stigma play a role, and provider-level and structural-level interventions to encourage early identification and treatment of persons at high risk are necessary.

SUMMARY

Persons with HIV should be screened with existing cardiovascular risk prediction tools, and those at high risk cardiovascular disease should be promptly referred for lifestyle and pharmacologic interventions as appropriate. System-level implementation research is ongoing in attempts to narrow the gap in cardiovascular care, particularly for vulnerable communities in low resource settings.

HIV patients’ perceptions of a potential multi-component mindfulness-based smoking cessation smartphone application intervention

Objectives

Cigarette smoking rates among people living with HIV (PLWH) in the US is triple that of the general population. PLWH smokers are a high-risk group for smoking-related health disparities and should be a prime focus for smoking cessation efforts. Our team has developed a novel evidence-based Mindfulness Training (MT) smoking cessation smartphone application (app), “Craving-to-Quit.” Using qualitative focus groups among PLWH smokers, this study aims to tailor and optimize the app’s content and design to PLWH’s unique psychosocial profile and needs.

Methods

We conducted 8 focus groups among PLWH smokers (n = 59; 47.5% females; ≥18 years) to gain insight into participants’ perceptions about the app, MT, and the feasibility and acceptability of adding two additional strategies (CM: Contingency Management; self-monitoring of anti-retroviral therapies intake [ART]) to further optimize the app. Participants were asked to practice MTs and watch videos from the app presented on a screen in the conference room to discuss their experience. Sessions were audio-taped, transcribed verbatim, and analyzed thematically using NVivo.

Results

Most participants were non-Hispanic black (67.8%), on a federal health insurance program (61.0%). Participants considered it easy to learn the app and thought that MT is helpful in reducing stress and motivating quit attempts and were supportive of adding CM and recommended providing $20-$50 weekly cash incentives to help in quitting. Participants felt that adding self-monitoring of ART is helpful but were concerned about confidentiality in case they lost their phone. Participants recommended making the app cost-free and adding information about smoking cessation medications and the negative effects of smoking among PLWH.

Conclusions

Findings will guide the development of a novel multi-component smoking cessation intervention app integrating MT, CM, and ART self-monitoring strategies. This intervention has the potential to address several barriers to quitting in PLWH. Further clinical research is needed to test this intervention.

A Smoking Cessation Mobile App for Persons Living With HIV: Preliminary Efficacy and Feasibility Study

BACKGROUND

The prevalence of smoking in the United States general population has gradually declined to the lowest rate ever recorded; however, this has not been true for persons with HIV.

OBJECTIVE

We conducted a pilot test to assess the feasibility and efficacy of the Lumme Quit Smoking mobile app and smartwatch combination with sensing capabilities to improve smoking cessation in persons with HIV.

METHODS

A total of 40 participants were enrolled in the study and randomly assigned 1:1 to the control arm, which received an 8-week supply of nicotine replacement therapy, a 30-minute smoking cessation counseling session, and weekly check-in calls with study staff, or to the intervention arm, which additionally received the Lumme Quit Smoking app and smartwatch.

RESULTS

Of the 40 participants enrolled, 37 completed the follow-up study assessments and 16 used the app every day during the 56-day period. During the 6-month recruitment and enrollment period, 122 people were screened for eligibility, with 67.2% (82/122) deemed ineligible. Smoking criteria and incompatible tech were the major reasons for ineligibility. There was no difference in the proportion of 7-day point prevalence abstinence by study arm and no significant decrease in exhaled carbon monoxide for the intervention and control arms separately. However, the average exhaled carbon monoxide decreased over time when analyzing both arms together (P=.02).

CONCLUSIONS

Results suggest excellent feasibility and acceptability of using a smoking sensor app among this smoking population. The knowledge gained from this research will enable the scientific community, clinicians, and community stakeholders to improve tobacco cessation outcomes for persons with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04808609; https://clinicaltrials.gov/ct2/show/NCT04808609.

The magnitude of undiagnosed hypertension and associated factors among HIV-positive patients attending antiretroviral therapy clinics of Butajira General Hospital, Gurage Zone, Southern Ethiopia

Objectives:

The study aimed to assess the magnitude of undiagnosed hypertension, and its associated factors among adult HIV-positive patients receiving antiretroviral therapy at Butajira General Hospital, southern Ethiopia.

Methods:

We applied an institutional-based cross-sectional study design at Butajira General Hospital from 1 May to 1 July 2021. We used a systematic random sampling technique to select the total number of participants. A structured interviewer-administered questionnaire was applied to collect the data (sociodemographic characteristics, clinical-related factors, and lifestyle-related factors from the study participants. Data were entered using Epi-data version 3.1 and analyzed by statistical package for social science version 25. We applied a multivariable logistic regression analysis model to identify variables significantly associated with hypertension.

Results:

The study comprised 388 participants with 39 years (10.6 SD) as the mean age of the participants. Of the total participants, 235 (60.6%) were female. In this study the magnitude of undiagnosed hypertension among HIV-positive patients was 18.8% (95% CI: 14.7%–23.2%). Having comorbidity of diabetes mellitus (adjusted odds ratio = 5.29, 95% CI: 2.154, 12.99), habit of alcohol drinking (adjusted odds ratio = 2.909, 95% CI: 1.306, 6.481), duration of antiretroviral therapy ⩾ 5 years (adjusted odds ratio = 3.087, 95% CI: 1.558, 6.115), and age ⩾ 40 years (adjusted odds ratio = 2.642, 95% CI: 1.450, 4.813) were factors significantly associated with undiagnosed hypertension.

Conclusions and recommendations:

The magnitude of undiagnosed hypertension among HIV-positive patients attending the antiretroviral therapy clinic of Butajira General Hospital is high. The findings of this study implied that HIV-positive patients attending antiretroviral therapy clinics should be monitored routinely for hypertension; especially participants aged ⩾40 years, highly active antiretroviral therapy duration ⩾5 years, having diabetes mellitus comorbidity need more attention. Primary healthcare integration is also vital to enhance the health of HIV-positive patients on antiretroviral therapy.

A new smoking cessation 'cascade' among women with or at risk for HIV infection

OBJECTIVES

The aim of this study was to define a smoking cessation 'cascade' among USA women with and without HIV and examine differences by sociodemographic characteristics.

DESIGN

An observational cohort study using data from smokers participating in the Women's Interagency HIV Study between 2014 and 2019.

METHODS

We followed 1165 women smokers with and without HIV from their first study visit in 2014 or 2015 until an attempt to quit smoking within approximately 3 years of follow-up, initial cessation (i.e. no restarting smoking within approximately 6 months of a quit attempt), and sustained cessation (i.e. no restarting smoking within approximately 12 months of a quit attempt). Using the Aalen-Johansen estimator, we estimated the cumulative probability of achieving each step, accounting for the competing risk of death.

RESULTS

Forty-five percent of smokers attempted to quit, 27% achieved initial cessation, and 14% achieved sustained cessation with no differences by HIV status. Women with some post-high school education were more likely to achieve each step than those with less education. Outcomes did not differ by race. Thirty-six percent [95% confidence interval (95% CI): 31-42] of uninsured women attempted to quit compared with 47% (95% CI: 44-50) with Medicaid and 49% (95% CI: 41-59) with private insurance.

CONCLUSION

To decrease smoking among USA women with and without HIV, targeted, multistage interventions, and increased insurance coverage are needed to address shortfalls along this cascade.

National Estimates of Prevalence, Time-Trend, and Correlates of Smoking in US People Living with HIV (NHANES 1999-2016)

OBJECTIVE

Approximately one in four deaths among people living with HIV (PLWH) in the United States can be attributed to cigarette smoking. Using a nationally representative sample of PLWH, this study examines the prevalence, time-trends, and correlates of current cigarette smoking among PLWH compared to people without HIV.

DESIGN

Secondary analysis of population-based cross-sectional biobehavioral survey.

METHODS

Data were pooled from the 1999-2016 National Health and Nutrition Examination Survey (NHANES). All adults (20-59 years) who self-reported their smoking status and were tested for HIV (HIV+ = 152; HIV- = 26 305) were included in the analysis. Prevalence with 95% confidence interval (95% CI), trend analysis by year and group (HIV+/HIV-), and multivariable logistic regression analyses were performed with the complex survey design adjustments.

RESULTS

Overall, 47.0% of PLWH were current smokers compared to 25.5% of those without HIV. From 1999 to 2016, the decline in smoking in PLWH was comparable to those without HIV (10.7% vs. 8.0%). PLWH smokers were more likely than PLWH nonsmokers to be substance users (adjusted odds ratio [aOR] = 17.52; 95% CI = 2.04 to 27.8). Compared to smokers without HIV, PLWH smokers were more likely to be older (1.10; 1.06 to 1.14), males (7.96; 2.50 to 25.40), non-Hispanic Black (10.45; 4.13 to 26.45), with depression (Patient Health Questionnaire-9 sum score ≥5) (3.79; 1.22 to 11.79), and less likely to be gay (0.02; 0.00 to 0.07).

CONCLUSION

Cigarette smoking among PLWH is a major public health problem in the United States. Targeted and tailored smoking cessation interventions that incorporate assessment and treatment of depression and co-occurring substance use are critical for PLWH, especially among those who are disproportionately affected by smoking and HIV (sexual minority).

IMPLICATIONS

This study offers important research implications in four areas:1. The decline in smoking among PLWH over 18 years has been modest, and half of PLWH are still smokers.2. More resources and efforts should be allocated to reduce cigarette smoking among PLWH.3. There is a critical need to develop and test culturally tailored smoking cessation interventions for minority subgroups who are most impacted by HIV infection and smoking (non-Hispanic Blacks and men who have sex with men)4. Smoking cessation interventions designed for PLWH should incorporate assessment and treatment of depression and substance use.

Magnitude of Hypertension and Associated Factors Among Human Immunodeficiency Virus Positive Adults Receiving Anti-Retroviral Therapy at Debre Markos Referral Hospital, Northwest, Ethiopia

BACKGROUND

People living with human immunodeficiency virus are at increased risk for cardiovascular diseases such as hypertension. Current evidence on the proportion of hypertension is essential to inform policymaker to strengthen interventions and regular monitoring of hypertension, yet information is scarce concerning hypertension in this study area.

OBJECTIVE

This study aimed to assess the magnitude of hypertension and associated factors among human immunodeficiency virus-positive adults receiving antiretroviral therapy at Debre Markos Referral Hospital, Northwest Ethiopia.

METHODS

A facility-based cross-sectional study was employed. Data were collected from systematically selected 412 participants using pre-tested, interviewer administered structured questionnaire. Data were entered and coded using Epi-data version 3.1 and analyzed using STATA version 14. The assumption of the logistic regression model was checked using a correlation matrix and Hosmer and Lemeshow's tests. Bivariate and multivariate logistic regression analyses were conducted.

RESULTS

In the present study, the prevalence of hypertension among human immunodeficiency virus-positive adults who received antiretroviral therapy was found to be 41.3% (95% CI; 36.7-46.0). Age groups 35-45 years (AOR: 2.48, 95% CI: 1.17, 5.27), greater than 45 years (AOR: 5.00, 95% CI: 2.190, 11.44), no physical exercise (AOR: 2.72, 95% CI: 1.33, 5.57), body mass index greater than or equal to 25 kg/m2 (AOR: 2.87 95% CI: 1.52, 5.39), and antiretroviral therapy regimens of 2 h/2f/2e/ABC+3TC+ATV/r (AOR: 3.05, 95% CI: 1.41, 6.60) were significantly associated with hypertension.

CONCLUSION

In the current study, the magnitude of hypertension was high among HIV-positive adults. Therefore, educating about the use of lifestyle change, counseling the use of regular physical activities, promoting weight reduction, and intervention in this situation are highly recommended.

Use of the Phase-Based Model of Smoking Treatment to Guide Intervention Development for Persons Living with HIV Who Self-Identify as African American Tobacco Smokers

Cigarette smoking is highly prevalent among persons living with the human immunodeficiency virus (HIV) (PLWH), with rates as high 50% as compared to 14% in the general U.S. population. Tobacco use causes morbidity and mortality in PLWH, and tobacco-related harm is substantially higher in PLWH than smokers in the general population, providing the scientific premise for developing effective tobacco cessation interventions in this population. To better address this issue, we conducted six focus group sessions with 45 African American smokers who are living with HIV to understand the barriers to smoking cessation and the strategies that would be helpful to overcome these barriers. We organized our findings by the Phase-Based Model of Smoking Treatment to understand the intervention components that are needed at each phase to help PLWH successfully quit smoking. Participants in our focus group sessions articulated key components for incorporation into tobacco cessation intervention for PLWH: a personalized plan for quitting, reminders about that plan, and a support system. Participants thought that their HIV and tobacco use were disassociated. Participants described barriers to the use of pharmacotherapy, including adverse side effects of the gum and patch and concerns about the negative health effects of some oral medications. Substance use was identified as a commonly co-occurring condition as well as a barrier to successfully ceasing to smoke tobacco products. In summary, these findings offer information on the components of a tobacco cessation intervention for PLWH, namely reminders, a support system, substance use treatment, and monitoring to prevent relapse.

Recurrence after hospitalization for acute coronary syndrome among HIV-infected and HIV-uninfected individuals

OBJECTIVES

We evaluated the association of HIV infection and immunodeficiency with acute coronary syndrome (ACS) recurrence, and with all-cause mortality as a secondary outcome, after hospitalization for ACS among HIV-infected and HIV-uninfected individuals.

METHODS

We conducted a retrospective cohort study within Kaiser Permanente Northern California of HIV-infected and HIV-uninfected adults discharged after ACS hospitalization [types: ST-elevation myocardial infarction (STEMI), non-STEMI, or unstable angina] during 1996-2010. We compared the outcomes of ACS recurrence and all-cause mortality within 3 years, both overall by HIV status and stratified by recent CD4 count, with HIV-uninfected individuals as the reference group. Hazard ratios (HRs) were obtained from Cox regression models with adjustment for age, sex, race/ethnicity, year, ACS type, smoking, and cardiovascular risk factors.

RESULTS

Among 226 HIV-infected and 86 321 HIV-uninfected individuals with ACS, HIV-infected individuals had a similar risk of ACS recurrence compared with HIV-uninfected individuals [HR 1.08; 95% confidence interval (CI) 0.76-1.54]. HIV infection was independently associated with all-cause mortality after ACS hospitalization overall (HR 2.52; 95% CI 1.81-3.52). In CD4-stratified models, post-ACS mortality was higher for HIV-infected individuals with CD4 counts of 201-499 cells/μL (HR 2.64; 95% CI 1.66-4.20) and < 200 cells/μL (HR 5.41; 95% CI 3.14-9.34), but not those with CD4 counts ≥ 500 cells/μL (HR 0.67; 95% CI 0.22-2.08), compared with HIV-uninfected individuals (P trend < 0.001).

CONCLUSIONS

HIV infection and immunodeficiency were not associated with recurrence of ACS after hospitalization. All-cause mortality was higher among HIV-infected compared with HIV-uninfected individuals, but there was no excess mortality risk among HIV-infected individuals with high CD4 counts.

Tobacco Use and Sustained Viral Suppression in Youth Living with HIV

Tobacco has been associated with worse HIV disease progression in adult samples of people living with HIV; however, studies have yet to examine these effects in youth living with HIV (YLWH). This study examined the association between tobacco smoking behaviors and sustained viral suppression among a sample of 820 YLWH who were recruited through the Adolescent Medicine Trials Network for HIV Interventions. Participants completed a cross-sectional survey and then staff abstracted viral suppression data from medical records for up to 26 weeks prior to enrollment. Overall, 20.4% of youth reported daily or almost daily tobacco use. In multivariable analyses, older age and daily or almost daily tobacco smoking, and ART adherence remained statistically significant in predicting sustained viral suppression over the study period. These findings underscore the need for tobacco screening and interventions in HIV care settings in order to identify youth in need of additional smoking cessation services.

Tobacco, illicit drugs use and risk of cardiovascular disease in patients living with HIV

PURPOSE OF REVIEW

There is a strong link between HIV, smoking and illicit drugs. This association could be clinically relevant as it may potentiate the risk of cardiovascular diseases (CVD). The purpose of this review is to bring readers up to date on issues concerning the cardiovascular risk associated with tobacco and illicit drugs in patients living with HIV (PLHIV), examining the studies related to this topic published in the last year.

RECENT FINDINGS

There is a strong association between smoking and atherosclerotic disease in PLHIV, reducing life expectancy secondary to CVD by up to 6 years. Illicit drugs were associated with increased risk of atherosclerotic problems but to a lesser extent than smoking. A significant association of drugs such as cocaine with subclinical coronary atherosclerosis been demonstrated. The relation of marijuana, heroin and amphetamines with atherosclerosis generates more controversy. However, those drugs are associated with cardiovascular morbidity, independently of smoking and other traditional risk factors.

SUMMARY

Tobacco and illicit drugs are linked to CVD in HIV patients. This leads to the need to create special programs to address the addiction to smoking and illicit drugs, in order to mitigate their consequences and reduce cardiovascular risk.

Switching from a ritonavir-boosted protease inhibitor to a dolutegravir-based regimen for maintenance of HIV viral suppression in patients with high cardiovascular risk

Supplemental Digital Content is available in the text

Objective:

To compare the efficacy, safety, and impact on lipid fractions of switching from a ritonavir-boosted protease inhibitor (PI/r) to a dolutegravir (DTG) regimen.

Methods:

HIV type 1-infected adults more than 50 years or with a Framingham score more than 10% were eligible if plasma HIV RNA less than 50 copies per ml for at least 24 weeks while on a PI/r regimen. Patients were randomized to switch to DTG or to remain on PI/r. Primary endpoints were: proportion maintaining HIV RNA less than 50 copies per ml and percentage change from baseline of total cholesterol at week 48.

Results:

In total, 415 patients (32 sites in six European countries) were randomized: 205 to DTG and 210 to continue PI/r. About 89% were men, 87% more than 50 years, 74% had a Framingham score more than 10%, with a median CD4⁺ cell count of 617 cells per μl and suppressed viremia for a median of 5 years. At week 48, in the intent-to-treat analysis, treatment success rate was 93.1% in DTG group and 95.2% in PI/r group (difference −2.1%, 95% confidence interval −6.6 to 2.4, noninferiority demonstrated). There were four virological failures with DTG and one with PI/r with no emergent resistance mutations. There was no significant difference in severe adverse events or grade 3 or 4 adverse events or treatment modifying adverse events. Total cholesterol and other lipid fractions (except high-density lipoprotein cholesterol) improved significantly (P < 0.001) in the DTG group regardless of PI/r at baseline.

Conclusion:

Switching to a DTG regimen in virologically suppressed HIV type 1 patients with high cardiovascular disease risk was noninferior, and significantly improved lipid profiles.

Hypertension in HIV-Infected Adults Compared with Similar but Uninfected Adults in China: Body Mass Index-Dependent Effects of Nadir CD4 Count

Hypertension is a growing problem in the HIV population. The relationship between low nadir CD4 count and hypertension in the HIV-infected population has been reported. However, the effect of nadir CD4 on hypertension due to a different body mass index (BMI) is yet to be fully elucidated. In this cross-sectional study, 345 HIV-infected participants aged ≥40 years were recruited. They were frequency matched and compared with age, sex, and education with HIV-uninfected adults (n = 345). Hypertension prevalence was lower in HIV-infected than in HIV-uninfected participants (23.8% vs. 31.9%; p = .011), but this association was not significant after adjusting for potential confounders. Among HIV-infected individuals, older age, overweight, with a family history of cardiovascular diseases, and nadir CD4 count <50 cells/μl were independently associated with hypertension. Stratifying individuals with BMI category revealed that nadir CD4 count-regardless if it was operationalized as a dichotomous variable (<50 cells/μl) or continuous variable-was found to be associated with hypertension among individuals who were underweight and obese, but not among those who were normal weight and overweight. Among HIV-uninfected individuals, older age and having a waist circumference above cutoff were significantly associated with hypertension. This is one of the first studies to demonstrate that the association of nadir CD4 and hypertension is observed in underweight and obese HIV-infected patients. While these results suggest that the relationship between nadir CD4 count and hypertension might be mediated by body weight, future longitudinal studies will be needed to validate the findings, including its causal pathways.

Risk indicators and effects of hypertension on HIV/AIDS disease progression among patients seen at Kenyatta hospital HIV care center

There is paucity of data on prevalence of hypertension and its effects on HIV/AIDS progression among patients at Kenyatta National Hospital (KNH), Kenya. This was a cross sectional study conducted between January and May 2015 at the KNH HIV Care Centre. Ethical approval was obtained from institutional ethics review board. HIV positive adult patients were recruited sequentially, and written informed consent obtained from each participant. Systematic sampling was used to select participants who were screened for blood pressure, body mass index (BMI) and lifestyle characteristics. Data on clinical parameters were extracted from patient records. A total of 297 participants (89 males and 208 females) were enrolled in the study. The participants were socially diverse in cultural beliefs, religious practices and lifestyles. Their ages ranged from 30 to 57 years, and the average age of males (M = 44.56, SD = 6.05) was higher than females (M = 42.29, SD = 6.16), p < .01. The prevalence of hypertension was found to be 23.2%. The relation between CD4 counts and creatinine was statistically significant, p < .01, as was the association between CD4 counts and BMI, p < .01. Hypertension is a highly prevalent co-morbidity in HIV patients. The risk factors include prolonged use of ART as well as increased body mass index. The effects of hypertension on HIV progression include low CD4+ T cell counts which complicate the underlying immunosuppression.

Smoking, alcohol and illicit drug use effects on survival in HIV-positive persons

PURPOSE OF REVIEW

In the era of effective antiretroviral therapy, HIV-positive patients experience an increase in non-AIDS associated comorbidities. Causes of death are now more frequently associated with ageing and smoking; alcohol and drug use are strongly linked to many of these causes.

RECENT FINDINGS

An almost equal life expectancy among HIV-positive people compared with HIV-negative population has been recently reported. However, life expectancy is reduced among HIV-positive smokers by at least 16 years and further reduced for people who have a history of excessive alcohol and drug use. Cohort studies report between a 1.5- and two-fold or greater increased mortality risk as a result of smoking. In a Danish population study, 61% of deaths in HIV-positive people were associated with smoking. Excessive alcohol and drug use are also elevated among specific HIV subpopulations and significantly impact morbidity and mortality. In the Veteran Affairs cohort study, moderate and excessive alcohol use increased mortality by 25-35% compared with low alcohol use.

SUMMARY

Despite the effective therapy, smoking, alcohol and drug use have a significant role in increased mortality and reduced life expectancy among HIV-positive people. These factors need to be in continued focus for the management and care of HIV-positive people.

Insulin Resistance and Markers of Inflammation in HIV-infected Ugandan Children in the CHAPAS-3 Trial

BACKGROUND

Few studies have investigated metabolic complications in HIV-infected African children and their relation with inflammation.

METHODS

We compared baseline and changes in insulin resistance [homeostatic model assessment of insulin resistance (HOMA-IR)] and in markers of inflammation over 48 weeks, in a subset of antiretroviral therapy (ART)-naive Ugandan children from the Children with HIV in Africa-Pharmacokinetics and Adherence/Acceptability of Simple Antiretroviral Regimens trial randomized to zidovudine-, stavudine- or abacavir (ABC)-based regimen. Nonparametric methods were used to explore between-group and within-group differences, and multivariable analysis to assess associations of HOMA-IR.

RESULTS

One-hundred eighteen children were enrolled, and median age (interquartile range) was 2.8 years (1.7-4.3). Baseline median HOMA-IR (interquartile range) was 0.49 (0.38-1.07) and similar between the arms. At week 48, median relative changes in HOMA-IR were 14% (-29% to 97%) in the zidovudine arm, -1% (-30% to 69%) in the stavudine arm and 6% (-34% to 124%) in the ABC arm (P ≤ 0.03 for all the arms compared with baseline, but P = 0.90 for between-group differences). Several inflammation markers significantly decreased in all study arms; soluble CD14 increased on ABC and did not change in the other 2 arms. In multivariate analysis, only changes in soluble CD163 were positively associated with HOMA-IR changes.

CONCLUSIONS

In ART-naive Ugandan children, HOMA-IR changed significantly after 48 weeks of ART and correlated with monocyte activation.

Global prevalence of hypertension among people living with HIV: a systematic review and meta-analysis

The purpose of this study was to estimate, through meta-analysis, the global prevalence of hypertension among people living with HIV (PLWH). A total of 49 studies published during 2011-2016 with 63,554 participants were included in analysis. These studies were conducted in America (25), Europe (13), Africa (10), and Asia (1) with data collected during 1996-2014. Prevalence of hypertension and confidence interval was estimated and stratified by participants' age, antiretroviral therapy (ART), and calendar-years using random effects modeling. The quality assessed using the Joanna Briggs Institute Prevalence Critical Appraisal Tool was high for all included studies. The estimated prevalence (95% confidence interval) of hypertension was 25.2% (21.2%, 29.6%) for the overall sample, 34.7% (27.4%, 42.8%) for ART-experienced, and 12.7% (7.4%, 20.8%) for ART-naïve participants. The estimated prevalence was found increased with age and in studies conducted after 2010. Hypertension among PLWH shows an increasing trend and is associated with receiving ART and older age. Findings of this study provide data for decision makers to incorporate blood pressure assessment in primary prevention and for researchers to further investigate factors and mechanisms related to hypertension among PLWH.

Behavioral Interventions for Tobacco Use in HIV-Infected Smokers: A Meta-Analysis

CONTEXT

Smoking is responsible for increased morbidity and mortality in HIV-infected smokers.

OBJECTIVE

To assess the efficacy of behavioral interventions for smoking cessation among HIV-infected smokers compared with the standard care.

DATA SOURCES

PubMed, Cochrane, CINHAL, PsychINFO, and Google Scholar were searched for randomized controlled trials published in English.

STUDY SELECTION

Eligibility criteria were randomized controlled trials with targeted behavioral interventions compared with standard of care (or enhanced standard of care) aimed at promoting abstinence in HIV-infected smokers. A total of 17,384 articles were found and 17,371 were excluded; 13 full text articles were obtained and reviewed, and 8 met the eligibility criteria (Κ = 0.94).

DATA EXTRACTION

The primary outcome was expired carbon monoxide-verified 7-day point prevalence abstinence rates. Adequate sequence generation and freedom from incomplete or selective outcome reporting was used to assess study quality.

RESULTS

A total of 1822 subjects from 8 studies yielded a statistically significant effect of behavioral interventions in increasing abstinence in HIV-infected smokers with a moderate effect size (relative risk: 1.51; 95% confidence interval: 1.17 to 1.95). Those studies with interventions of 8 sessions or more had a large effect size for abstinence (relative risk: 2.88; 95% confidence interval: 1.89 to 4.61). When stratified by the number of sessions, there was no heterogeneity.

CONCLUSIONS

Targeted behavioral smoking cessation interventions are efficacious. Interventions consisting of 8 sessions or more had the greatest treatment efficacy.

Unchanged Levels of Soluble CD14 and IL-6 Over Time Predict Serious Non-AIDS Events in HIV-1-Infected People

HIV-1-infected persons have increased risk of serious non-AIDS events (SNAEs) despite suppressive antiretroviral therapy. Increased circulating levels of soluble CD14 (sCD14), soluble CD163 (sCD163), and interleukin-6 (IL-6) at a single time point have been associated with SNAEs. However, whether changes in these biomarker levels predict SNAEs in HIV-1-infected persons is unknown. We hypothesized that greater decreases in inflammatory biomarkers would be associated with fewer SNAEs. We identified 39 patients with SNAEs, including major cardiovascular events, end stage renal disease, decompensated cirrhosis, non-AIDS-defining malignancies, and death of unknown cause, and age- and sex-matched HIV-1-infected controls. sCD14, sCD163, and IL-6 were measured at study enrollment (T1) and proximal to the event (T2) or equivalent duration in matched controls. Over ∼34 months, unchanged rather than decreasing levels of sCD14 and IL-6 predicted SNAEs. Older age and current illicit substance abuse, but not HCV coinfection, were associated with SNAEs. In a multivariate analysis, older age, illicit substance use, and unchanged IL-6 levels remained significantly associated with SNAEs. Thus, the trajectories of sCD14 and IL-6 levels predict SNAEs. Interventions to decrease illicit substance use may decrease the risk of SNAEs in HIV-1-infected persons.

[Cross sectional study of comorbidities and concomitant medications in a cohort of human immunodeficiency virus-infected patients]

Objetivo

Valorar la prevalencia de comorbilidades, tratamientos concomitantes y episodios adversos asociados a la medicación en una cohorte de pacientes con infección por VIH.

Diseño

Estudio transversal multicéntrico.

Emplazamiento

Consultas externas especializadas del servicio de Enfermedades Infecciosas o Medicina Interna de 3 hospitales de la comunidad autónoma del País Vasco.

Participantes

Durante 3 meses se seleccionaron de forma aleatoria pacientes con los siguientes criterios de inclusión: infección por VIH, edad superior a 18 años, tratamiento antirretroviral (TAR) desde al menos 6 meses y pauta de TAR estable las últimas 4 semanas. Se incluyeron 224 pacientes del total de 225 previstos.

Mediciones principales

Se recogieron mediante formulario datos epidemiológicos y antropométricos relativos a la infección por VIH, comorbilidades, tratamientos concomitantes y episodios adversos.

Resultados

El 95,5% de los pacientes presentaban alguna comorbilidad, siendo las más frecuentes: infección por VHC (51,3%), dislipidemias (37,9%), glucemia basal alterada o diabetes mellitus (21,9%) e hipertensión arterial (21,9%). El 69,2% tomaban alguna medicación concomitante al TAR: ansiolíticos (21,4%), antihipertensivos (19,6%), inhibidores de la bomba de protones (17,9%), estatinas (17%) o antidepresivos (16,5%). El 62,9% presentaban algún efecto adverso, los más frecuentes la alteración de la distribución de grasa corporal (32,6%) y digestivos (24,1%).

Conclusiones

Nuestros pacientes con infección por VIH son cada vez mayores, con mayor número de comorbilidades, con uso muy frecuente de tratamientos concomitantes y elevada prevalencia de episodios adversos. Esto obliga a un abordaje multidisciplinar y a una labor coordinada con atención primaria.

Improvements over time in short-term mortality following myocardial infarction in HIV-positive individuals

OBJECTIVE

Few studies have described mortality and clinical outcomes after myocardial infarction (MI) in the HIV-positive population. This study evaluated changes in short-term mortality after MI in HIV-positive individuals in the D:A:D Study, and investigated possible reasons for any changes seen.

DESIGN

Prospective cohort study.

METHODS

Demographic, cardiovascular disease (CVD)/HIV-related characteristics and CVD-related interventions (invasive cardiovascular procedures and drug interventions) were summarized at the time of and following an MI. Associations between calendar year and mortality in the first month after MI were identified using logistic regression with adjustment for confounders, including interventions received in the first month after MI.

RESULTS

One thousand and eight HIV-positive individuals experiencing an MI over the period 1999-2014 were included. The absolute number of MIs decreased from 214 (1999-2002) to 154 (2011-2014). Whilst the CVD risk profile remained high over time, the HIV status improved. The use of CVD-related interventions after MI appeared to increase over time. The proportion of individuals who died in the first month after MI dropped from 26.6% in 1999-2002 to 8.4% in 2011-2014. Later calendar year was associated with decreased short-term mortality; this effect was attenuated after adjusting for CVD-related interventions received in the first month after MI [odds ratio changed from 0.88 (95% confidence interval 0.83, 0.93) to 0.97 (0.91, 1.02)].

CONCLUSION

Improvements in short-term survival after MI appear to be largely driven by improved medical management of CVD risk in HIV-positive individuals after MI. Efforts are still needed to treat CVD risk factors and increase access to CVD-related interventions.

Interventions for tobacco use cessation in people living with HIV and AIDS

BACKGROUND

Tobacco use is highly prevalent amongst people living with HIV/AIDS (PLWHA) and has a substantial impact on morbidity and mortality.

OBJECTIVES

To assess the effectiveness of interventions to motivate and assist tobacco use cessation for people living with HIV/AIDS (PLWHA), and to evaluate the risks of any harms associated with those interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO in June 2015. We also searched EThOS, ProQuest, four clinical trial registries, reference lists of articles, and searched for conference abstracts using Web of Science and handsearched speciality conference databases.

SELECTION CRITERIA

Controlled trials of behavioural or pharmacological interventions for tobacco cessation for PLWHA.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised electronic data collection form. They extracted data on the nature of the intervention, participants, and proportion achieving abstinence and they contacted study authors to obtain missing information. We collected data on long-term (greater than or equal to six months) and short-term (less than six months) outcomes. Where appropriate, we performed meta-analysis and estimated the pooled effects using the Mantel-Haenszel fixed-effect method. Two authors independently assessed and reported the risk of bias according to prespecified criteria.

MAIN RESULTS

We identified 14 studies relevant to this review, of which we included 12 in a meta-analysis (n = 2087). All studies provided an intervention combining behavioural support and pharmacotherapy, and in most studies this was compared to a less intensive control, typically comprising a brief behavioural intervention plus pharmacotherapy.There was moderate quality evidence from six studies for the long-term abstinence outcome, which showed no evidence of effect for more intense cessation interventions: (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.72 to 1.39) with no evidence of heterogeneity (I(2) = 0%). The pooled long-term abstinence was 8% in both intervention and control conditions. There was very low quality evidence from 11 studies that more intense tobacco cessation interventions were effective in achieving short-term abstinence (RR 1.51, 95% CI 1.15 to 2.00); there was moderate heterogeneity (I(2) = 42%). Abstinence in the control group at short-term follow-up was 8% (n = 67/848) and in the intervention group was 13% (n = 118/937). The effect of tailoring the intervention for PLWHA was unclear. We further investigated the effect of intensity of behavioural intervention via number of sessions and total duration of contact. We failed to detect evidence of a difference in effect according to either measure of intensity, although there were few studies in each subgroup. It was not possible to perform the planned analysis of adverse events or HIV outcomes since these were not reported in more than one study.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that combined tobacco cessation interventions provide similar outcomes to controls in PLWHA in the long-term. There is very low quality evidence that combined tobacco cessation interventions were effective in helping PLWHA achieve short-term abstinence. Despite this, tobacco cessation interventions should be offered to PLWHA, since even non-sustained periods of abstinence have proven benefits. Further large, well designed studies of cessation interventions for PLWHA are needed.

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

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

Factors Associated With Smoking Status among HIV-Positive Patients in Routine Clinical Care

BACKGROUND

Treatment-related reductions in morbidity and mortality among human immunodeficiency virus (HIV)-positive patients have been attenuated by cigarette smoking, which increases risk of cardiovascular, respiratory, and neoplastic diseases. This study investigated factors associated with smoking status among HIV-positive patients.

METHODS

This cross-sectional study included 2,464 HIV-positive patients attending the HIV Clinic at the University of Alabama at Birmingham between April 2008 and December 2013. Smoking status (current, former, never), psychosocial factors, and clinical characteristics were assessed. Multinomial logistic regression was used to obtain unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association of the various factors with smoking status.

RESULTS

Among HIV-positive patients (mean age 45 years, 75% male, 55% African-American), the majority reported a history of smoking (39% current and 22% former smokers). In adjusted models, patient characteristics associated with increased odds of current smoking were male gender (OR for heterosexual men, 1.8 [95% CI: 1.3-2.6]; for men who have sex with men, 1.5 [1.1-1.9]), history of respiratory diseases (1.5 [1.2-1.9]), unsuppressed HIV viral load (>50 copies/mL) (1.5 [1.1-1.9]), depression (1.6 [1.3-2.0]), anxiety (1.6 [1.2-2.1]), and prior and current substance abuse (4.7 [3.6-6.1] and 8.3 [5.3-13.3] respectively). Male gender, anxiety, and substance abuse were also associated with being a former smoker.

CONCLUSIONS

Smoking was common among HIV-positive patients, with several psychosocial factors associated with current and former smoking. This suggests smoking cessation programs in HIV clinic settings may achieve greater impact by integrating interventions that also address illicit substance abuse and mental health.

HIV-related metabolic comorbidities in the current ART era

Despite effective antiretroviral therapy (ART), HIV-infected individuals have residual chronic immune activation that contributes to the pathogenesis of HIV infection. This immune system dysregulation is a pathogenic state manifested by very low naïve T-cell numbers and increased terminally differentiated effector cells that generate excessive proinflammatory cytokines with limited functionality. Immune exhaustion leaves an individual at risk for accelerated aging-related diseases, including renal dysfunction, atherosclerosis, diabetes mellitus, and osteoporosis. We highlight research that clarifies the role of HIV, ART, and other factors that contribute to the development of these diseases among HIV-infected persons.

Myocardial infarction among Danish HIV-infected individuals: population-attributable fractions associated with smoking

BACKGROUND

Human immunodeficiency virus-infected individuals have increased risk of myocardial infarction (MI); however, the contribution from smoking and potentiating effects of HIV are controversial.

METHODS

From the Danish HIV Cohort Study and the Copenhagen General Population Study, we identified 3251 HIV-infected individuals and 13 004 population controls matched on age and gender. Data on MI were obtained from the National Hospital Registry and the National Registry of Causes of Death. We calculated adjusted incidence rate ratios (aIRR) for risk of MI and population-attributable fractions (PAF) of MI associated with smoking.

RESULTS

In never smokers, HIV was not associated with an increased risk of MI (aIRR, 1.01; 95% confidence interval [CI], .41-2.54). In previous and current smokers, HIV was associated with a substantially increased risk of MI (aIRR, 1.78; 95% CI, .75-4.24 and aIRR, 2.83; 95% CI, 1.71-4.70). The PAF associated with ever smoking (previous or current) was 72% (95% CI, 55%-82%) for HIV-infected individuals and 24% (95% CI, 3%-40%) for population controls. If all current smokers stopped smoking, 42% (95% CI, 21%-57%) and 21% (95% CI, 12%-28%) of all MIs could potentially be avoided in these 2 populations.

CONCLUSIONS

Smoking is associated with a higher risk of MI in the HIV-infected population than in the general population. Approximately 3 of 4 MIs among HIV-infected individuals are associated with ever smoking compared with only 1 of 4 MIs among population controls. Smoking cessation could potentially prevent more than 40% of MIs among HIV-infected individuals, and smoking cessation should be a primary focus in modern HIV care.

Risk of coronary heart disease in patients with HIV infection

The lives of individuals infected with HIV who have access to combination antiretroviral therapy (cART) are substantially prolonged, which increases the risk of developing non-AIDS comorbidities, including coronary heart disease (CHD). In Europe and the USA, individuals with HIV infection have a ∼1.5-fold increased risk of myocardial infarction relative to uninfected individuals. In Africa, the relative risk of myocardial infarction is unknown, but broadened access to life-extending cART suggests that rates of CHD will rise in this and other resource-constrained regions. Atherogenesis in HIV is affected by complex interactions between traditional and immune risk factors. cART has varied, regimen-specific effects on metabolic risk factors. Overall, cART seems to lessen proatherogenic immune activation, but does not eliminate it even in patients in whom viraemia is suppressed. Current strategies to decrease the risk of CHD in individuals infected with HIV include early initiation of cART regimens with the fewest metabolic adverse effects, and careful management of traditional CHD risk factors throughout treatment. Future strategies to prevent CHD in patients with HIV infection might involve the use of HIV-tailored CHD risk-prediction paradigms and the administration of therapies alongside cART that will further decrease proatherogenic HIV-specific immune activation.

Diabetes mellitus type 2 and abnormal glucose metabolism in the setting of human immunodeficiency virus

As the modern era of combination antiretroviral therapy has increased life expectancy for individuals infected with the human immunodeficiency virus (HIV), type 2 diabetes mellitus and disorders of glucose metabolism have emerged as an important issue in the care of this population. Multiple mechanisms, both specific and nonspecific to HIV, underlie a significant prevalence. Although best-practice diagnostic testing remains unclear, the risks associated with diabetes in the setting of HIV are well characterized, ranging from organ-specific damage to socioeconomic decline. As population-specific treatment data are limited, current guidelines serve as a basis for ongoing management.

Relation between K469E gene polymorphism of ICAM-1 and recurrence of ACS and cardiovascular mortality

OBJECTIVE

To explore the relation between K469E gene polymorphism of intercellular adhesion molecular-1 (ICAM-1) and the recurrence of ACS and cardiovascular mortality.

METHODS

A total of 185 patients with ACS hospitalized in Department of Cardiology in our hospital from Sep 2007 to Sep 2008 were selected as objectives. Polymerase chain reaction was used to analyze K469E gene polymorphism of ICAM-1. According to the genotypes, they were divided into two groups: group with K allele (KK+KE) and group without K allele (EE). The two groups were followed up prospectively for five years and blood lipid, blood pressure, blood glucose, recurrence and death of ACS were collected when the patients left hospital. The relation between ICAM-1 gene polymorphism and the recurrence of ACS and cardiovascular mortality was analyzed by Logistic regression.

RESULTS

After long-term follow-up, it was found that ACS recurred on 71 cases (38.4%) and 10 cases died, among which 3 cases died of cardiovascular disease. The recurrence of ACS and cardiovascular mortality in group with K allele were remarkably higher than that in group without K allele (P<0.01). After multivariate Logistic regression adjusted ages, gender, weight indexes, TC, LDL-C, TG, smoking, drinking, family history of cardiovascular disease, history of hypertension and the severity of coronary artery disease, the risks of ACS recurrence and cardiovascular mortality in group with genotype KK+KE was 3.31 and 3.53 times of those in group with genotype EE respectively (P<0.01). When the independent variable of hypertension was introduced in regression analysis, the risks of ACS recurrence and cardiovascular mortality in group with K allele both decreased (P<0.05). When the independent variable of HDL-C was introduced, different genotypes of ICAM-1 weren't relevant with ACS recurrence and cardiovascular mortality (P>0.05).

CONCLUSIONS

K469E gene polymorphism of ICAM-1 was related to ACS recurrence and cardiovascular mortality, K allele probably an independent risky factor and hypertension and to which the level of HDL-C were closely related.

HIV and the heart: the impact of antiretroviral therapy: a global perspective

From a global perspective, cardiovascular disease (CVD) in human immunodeficiency virus (HIV) may result from cardiac involvement upon presentation of opportunistic infections in the presence of advanced immunosuppression, be a consequence of HIV-induced immune activation or derive from antiretroviral therapy-associated dyslipidaemia and insulin resistance. Indeed, in developed countries with unlimited access to antiretroviral therapy CVD has become one of the major causes of death in HIV. Therefore, cardiovascular risk reduction and lifestyle modifications are essential and careful selection of the antiretroviral drugs according to underlying cardiovascular risk factors of great importance. In developing countries with delayed roll-out of antiretroviral therapy pericardial disease (often related to TB), HIV-associated cardiomyopathy, and HIV-associated pulmonary hypertension are the most common cardiac manifestations in HIV. In Africa, the epicentre of the HIV epidemic, dynamic socio-economic and lifestyle factors characteristic of epidemiological transition appear to have positioned the urban African community at the cross-roads between historically prevalent and 'new' forms of CVD, such as coronary artery disease. In this context, cardiovascular risk assessment of HIV-infected patients will become a critical element of care in developing countries similar to the developed world, and access to antiretroviral therapy with little or no impact on lipid and glucose metabolism of importance to reduce CVD in HIV.

Effects of smoking on non-AIDS-related morbidity in HIV-infected patients

Tobacco smoking has many adverse health consequences. Patients with human immunodeficiency virus (HIV) infection smoke at very high rates, and many of the comorbidities associated with smoking in the general population are more prevalent in this population. It is likely that a combination of higher smoking rates along with an altered response to cigarette smoke throughout the body in persons with HIV infection leads to increased rates of the known conditions related to smoking. Several AIDS-defining conditions associated with smoking have been reviewed elsewhere. This review aims to summarize the data on non-AIDS-related health consequences of smoking in the HIV-infected population and explore evidence for the potential compounding effects on chronic systemic inflammation due to HIV infection and smoking.