Risk of cardiovascular disease in HIV, hepatitis C, or HIV/hepatitis C patients compared to the general population

Cardiovascular Risk in Patients with Chronic Hepatitis C Treated with Direct Acting Antivirals

Background: Chronic hepatitis C (CHC) is associated with hepatic and extrahepatic complications, including cardiovascular disease (CVD). The effects of sustained virological response (SVR) and liver fibrosis on CVD risk are not well established. Aims: We aim to assess the dynamics of Fibrosis-4 (FIB-4) and Atherosclerotic Cardiovascular Disease 2013 (ASCVD) scores up to three years after direct acting antivirals (DAA) treatment and explore the time-dependent association between the two scores. Methods: We included consecutive CHC patients treated with DAA and followed up with them for three years. Outcomes were changes from baseline (before DAA) in ASCVD and FIB-4 scores, measured at the end of treatment, 12-, 24-, and 36-months follow-up. Results: In total, 91 patients with CHC were finally included (median age: 66 years (IQR = 58−72 years); 43% females). Median follow-up was 2 years (1−3 years) and all patients reached SVR. The ASCVD score did not significantly change from baseline (Mean = 17.2%, 95% CI 14.1, 20.3), but the FIB-4 score significantly decreased at any time-point by an average of 0.8 (95% CI 0.78, 0.82, p < 0.001). Elevated FIB-4 scores at one (β = 1.16, p < 0.001) and three years (β = 2.52, p < 0.001) were associated with an increased ASCVD score. Clinically, two participants- with non-decreasing FIB-4 scores after treatment- had acute coronary syndrome at the end of treatment and one year follow-up, respectively. Conclusions: In our study, we found that FIB-4 and ASCVD scores exhibited a positive correlation irrespective of time-point after treatment. Larger studies are essential to further investigate the utility of FIB-4 scores in cardiovascular risk assessment.

Characteristics of Adults With Hepatitis C Virus: Evidence From the National Health and Nutrition Examination Survey 2011-2012

Hepatitis C virus (HCV) infects more than 3 million people in the United States (U.S.). Long-term complications of hepatitis C infection result in increased liver disease and financial burden for the nation. The purpose of this study was to identify characteristics of adults with HCV in the U.S. This secondary, descriptive study analyzed data from the 2011-2012 National Health and Nutrition Examination Survey. The weighted sample included 2,075,749 adults diagnosed with HCV. Descriptive statistics were calculated. The findings revealed that most adults in the U.S. with HCV were insured non-Hispanic, white males, aged 45 to 64 years. Almost half of adults with HCV denied a liver condition. Several participants either were co-infected or had previous infection (82%) with other hepatitis. Substance use (53.5%), alcohol use (96%), and cigarette use (88.6%) among adults with HCV were higher than previously reported. A majority of adults were noncompliant with hepatitis A and B vaccination series completion (67% and 65.1%, respectively). Medication adherence was higher than other reported cases. Adults with HCV have increased mental health symptoms (67.1%) and do not routinely visit a mental health professional (90.2%). HCV-infected adults are likely to use alcohol, cigarettes, and/or other substances. Adults with HCV have significant mental health issues, but rarely access care. Medication adherence was higher than expected for this cohort. The findings provide information for nurses to develop individualized plans of care and identify at-risk individuals for treatment noncompliance.

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

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

Comparison of Predicted Cardiovascular Risk Profiles by Different CVD Risk-Scoring Algorithms between HIV-1-Infected and Uninfected Adults: A Cross-Sectional Study in Tanzania

Purpose

Cardiovascular disease (CVD) risk assessment is a suitable way to differentiate between high-risk individuals requiring intervention and risk modification, and those at low risk. However, concerns have been raised when adopting a CVD-risk prediction algorithm for HIV-infected patients in sub-Saharan Africa.

Patients and Methods

We compared cardiovascular risk profiles between HIV-infected (with and without antiretroviral therapy (ART)) and HIV-uninfected adults as predicted by the American College of Cardiology/American Heart Association (ASCVD) and the Framingham cardiovascular risk score (FRS) algorithms and assessed the concordance of the algorithms in predicting 10-year CVD risk separately in HIV-infected and uninfected groups in a hospital-based cross-sectional study in Tanzania. A cross-sectional hospital-based study including 40 HIV-infected ART-naive, 64 HIV-infected on ART, and 50 HIV-uninfected adults was conducted. Traditional cardiovascular risk factors were determined by standard investigations. The primary outcome was the absolute 10-year CVD risk score based on the two algorithms.

Results

Compared to HIV-uninfected, HIV-infected adults were classified at a higher 10-year CVD risk. ASCVD algorithms predicted a higher proportion of high-risk individuals compared to FRS in both HIV-infected and uninfected groups. The concordance between ASCVD and FRS-lipid algorithms was reasonable for both HIV-infected and uninfected groups though relatively higher in the HIV-uninfected group.

Conclusion

HIV-infected individuals have a higher 10-year cardiovascular risk compared to HIV-uninfected persons. The concordance between ASCVD and FRS-lipid algorithms is reasonable in both HIV-uninfected and infected persons in Tanzania. Development of an HIV-specific algorithm is needed to accurately predict CVD risk in this population at high-risk.

Cardiovascular risk factors in HIV infected individuals: Comparison with general adult control population in Greece

Background

Although combined antiretroviral therapy has substantially improved the prognosis of people living with HIV (PLHIV), mortality remains higher compared to the general population, mainly due to higher prevalence of non-HIV-related comorbidities, including cardiovascular diseases (CVD). We assessed the prevalence of CVD risk and its contributing factors in adult PLHIV versus general population controls in Greece.

Settings

Cross-sectional comparison of PLHIV (Athens-Multicenter-AIDS-Cohort-Study; AMACS) versus general population controls (National health examination survey; EMENO).

Methods

All HIV-infected adults with ≥1 measurement of interest (blood pressure, lipids, glucose, weight, height) between 2012–2014 and all EMENO participants (2014–2016) were included. Ten-year total CVD risk was estimated using the Framingham (FRS) or the Systematic Coronary Risk Evaluation (SCORE) equations.

Results

5839 PLHIV (median age:41.6 years, 85.4% males) and 4820 controls (median age:48 years, 48.4% males) were included. Adjusting for age, sex and origin, PLHIV were more likely to be current smokers (adjusted OR:1.53 [95% CI:1.35–1.74]) and dyslipidemic (aOR:1.18; [1.04–1.34]), less likely to be obese (aOR:0.44 [0.38–0.52], with no differences in hypertension, diabetes or high (≥20%) FRS but with greater odds of high (≥5%) SCORE (aOR:1.55 [1.05–2.30]). Further adjustment for educational level, anti-HCV positivity and BMI showed higher prevalence of hypertension in PLHIV.

Conclusions

Despite the relative absence of obesity, PLHIV have higher prevalence of traditional CVD risk factors and higher risk of fatal CVD compared to general population. Regular screening and early management of CVD risk factors in PLHIV should be of high priority for CVD prevention.

Successful Kidney Transplantation in a Recipient Coinfected with Hepatitis C Genotype 2 and HIV from a Donor Infected with Hepatitis C Genotype 1 in the Direct-Acting Antiviral Era

Despite significant advances in transplantation of HIV-infected individuals, little is known about HIV coinfected patients with hepatitis C virus (HCV) genotypes other than genotype 1, especially when receiving HCV-infected organs with a different genotype. We describe the first case of kidney transplantation in a man coinfected with hepatitis C and HIV in our state. To our knowledge, this is also the first report of an HIV/HCV/HBV tri-infected patient with non-1 (2a) HCV genotype who received an HCV-infected kidney graft with the discordant genotype (1a), to which he converted after transplant. Our case study highlights the following: (1) transplant centers need to monitor wait times for an HCV-infected organ and regularly assess the risk of delaying HCV antiviral treatment for HCV-infected transplant candidates in anticipation of the transplant from an HCV-infected donor; (2) closer monitoring of tacrolimus levels during the early phases of anti-HCV protease inhibitor introduction and discontinuation may be indicated; (3) donor genotype transmission can occur; (4) HIV/HCV coinfected transplant candidates require a holistic approach with emphasis on the cardiovascular risk profile and low threshold for cardiac catheterization as part of their pretransplant evaluation.

The Influence of Antiretroviral Therapy on Hepatitis C Virus Viral Load and Liver Fibrosis in Human Immunodeficiency Virus-Coinfected Patients: An Observational Study

BACKGROUND

The role of antiretroviral therapy (ART) for Hepatitis C viral load (HCV-VL) and liver fibrosis is poorly understood. This study aimed at evaluating the influence of ART on HCV-VL and liver fibrosis in human immunodeficiency virus (HIV)/HCV-coinfected patients.

METHODS

We conducted a retrospective cohort study of HIV/HCV-coinfected patients followed at a tertiary university hospital.

RESULTS

In total, 143 patients were included. In 61 patients, ART initiation was accompanied by an increase in HCV-VL and a decrease in HIV viral load (HIV-VL), whereas ART suspension led to a decrease in HCV-VL and an increase in HIV-VL. Among the 55 HIV-suppressed patients who switched to a raltegravir (RAL)-containing regimen, median HCV-VL levels decreased significantly, while switching to a rilpivirine-containing regimen did not yield a significant reduction.

DISCUSSION

If the -treatment of chronic hepatitis starts before ART, ART initiation should be delayed as much as possible. If ART has been started, it is advisable to wait 1 year before initiating chronic hepatitis treatment. RAL as the third agent in an ART regimen could be beneficial in HIV/HCV-coinfected patients, in comparison to other antiretroviral drugs.

CONCLUSION

The start and the suspension of ART significantly interferes with HCV-VL in HIV/HCV-coinfected patients.

Excess heart age in adult outpatients in routine HIV care

OBJECTIVE

Cardiovascular disease (CVD) is a common cause of morbidity and mortality among persons living with HIV (PLWH). We used individual cardiovascular risk factor profiles to estimate heart age for PLWH in medical care in the United States.

DESIGN

Cross-sectional analyses of HIV Outpatient Study (HOPS) data METHODS:: Included in this analysis were participants aged 30-74 years, without prior CVD, with at least two HOPS clinic visits during 2010-2017, at least 1-year of follow-up, and available covariate data. We calculated age and race/ethnicity-adjusted heart age and excess heart age (chronological age - heart age), using a Framingham risk score-based model.

RESULTS

We analyzed data from 2467 men and 619 women (mean chronologic age 49.3 and 49.1 years, and 23.6% and 54.6% Non-Hispanic/Latino black, respectively). Adjusted excess heart age was 11.5 years (95% confidence interval, 11.1-12.0) among men and 13.1 years (12.0-14.1) among women. Excess heart age was seen among all age groups beginning with persons aged 30-39 years [men, 7.8 (6.9-8.8); women, 7.7 (4.9-10.4)], with the highest excess heart age among participants aged 50-59 years [men, 13.7 years (13.0-14.4); women, 16.4 years (14.8-18.0)]. More than 50% of participants had an excess heart age of at least 10 years.

CONCLUSIONS

Excess heart age is common among PLWH, begins in early adulthood, and impacts both women and men. Among PLWH, CVD risk factors should be addressed early and proactively. Routine use of the heart age calculator may help optimize CVD risk stratification and facilitate interventions for aging PLWH.

Prevalence and related drug cost of comorbidities in HIV-infected patients receiving highly active antiretroviral therapy in Taiwan: A cross-sectional study

BACKGROUND

To determine the prevalence of chronic comorbidities and associated medication costs in Taiwanese HIV patients in order to increase awareness of the disease burden among healthcare providers and patients.

METHODS

HIV-diagnosed patients receiving highly active antiretroviral therapy (HAART; 2010-2013) were identified from the Taiwan National Health Insurance Research Database with the corresponding International Classification of Diseases, ninth revision (ICD-9) code. Comorbidities (type II diabetes mellitus, hypertension, dyslipidemia, major depressive disorder, acute coronary syndrome, and cholelithiasis/nephrolithiasis) were identified according to ICD-9 or relevant medication use. Comorbidity medication and associated costs were identified using the drug classification code from the Anatomical Therapeutic Chemical classification system code series and series outpatient prescriptions.

RESULTS

Of 20,726 HIV-diagnosed Taiwanese patients (2010-2013), 13,142 receiving HAART were analyzed. Prevalence of all chronic comorbidities was significantly greater (p < 0.0001) in patients aged ≥40 years versus <40 years (diabetes mellitus, 14.95% vs. 3.30%; hypertension, 46.73% vs. 26.83%; dyslipidemia, 34.93% vs. 18.37%; depression, 23.75% vs. 19.88%; acute coronary syndrome, 1.16% vs. 0.21%; nephrolithiasis/cholelithiasis, 7.26% vs. 4.56%; >2 comorbidities, 24.80% vs. 7.21%). An increase in comorbidity medication spending (2010 vs. 2013 medication costs) was observed (antidyslipidemia, $88,878 vs. $168,180; antihyperglycemia, $32,372 vs. $73,518; antidepressants, $78,220 vs. $125,971; sedatives, $60,009 vs. $85,055; antihypertension, $47,115 vs. $95,134), contributing to overall treatment costs increasing almost two-fold from 2010 to 2013.

CONCLUSIONS

Among HIV-infected Taiwanese patients receiving HAART, significant increases in comorbidity prevalence with age, along with rising comorbidity medication costs, suggest the need for preventative as well as chronic care.

Cardiovascular disease risk in patients with hepatitis C infection: Results from two general population health surveys in Canada and the United States (2007-2017)

The role of hepatitis C virus (HCV) infection in increasing the risk of cardiovascular disease (CVD) is controversial. The objective of the present study is to estimate the 10-year risk of CVD in HCV- positive subjects and describe their profile of cardiometabolic risk markers compared to HCV-negative subjects. We conducted a cross-sectional study to estimate 10-year CVD risk, calculated using the Framingham Risk Score (FRS), in participants from the Canadian Health Measures Survey (CHMS; 2007–2015, n = 10,115) and the US-National Health and Nutrition Examination Survey (NHANES; 2007–2016, n = 16,668). Subjects included in our analysis were aged 30 to 74 years with no prior history of CVD. FRS estimates, sociodemographic and cardiometabolic risk factors were compared between HCV- positive and -negative subjects in the two surveys. HCV-positive subjects had a distinct sociodemographic profile compared to their HCV-negative counterparts. Cardiometabolic risk factors, inflammatory markers and serum levels of micronutrients were comparable between the two survey populations, both in HCV-positive and -negative subjects. The average FRS in HCV-positive patients was in the range of “intermediate” 10-year CVD risk (i.e., 10–20%) and was significantly higher (P<0.01) than their HCV-negative counterparts who were within the “low” 10-year CVD risk range (i.e., ≤10%). Using a multivariable linear regression model adjusted for ethnicity, number of metabolic syndrome components and BMI, HCV infection was significantly associated with a 2.5–3.5% absolute risk increase of 10-year CVD (P<0.01). The results of the present study suggest a potential association between HCV infection and risk of subclinical and clinical CVD. The expansion of anti-HCV therapy may also contribute to reduced CVD risk and burden in patients with chronic HCV infection and should be explored further in other datasets and population modelling studies.

Cardiovascular Disease Risk Assessment in the United States and Low- and Middle-Income Countries Using Predicted Heart/Vascular Age

Almost 80% of the global burden of cardiovascular disease (CVD) occurs in low- and middle-income countries (LMICs). However, LMICs do not have well-established, low-technology ways to quantify and communicate CVD risk at population or individual levels. We examined predicted heart/vascular age (PHA) in six LMICs and the United States. Data were from CVD-free adults in World Health Organization Study on Global Aging and Adult Health (n = 29094) and US National Health and Nutritional Examination Survey (n = 6726). PHA was calculated using the non-laboratory Framingham CVD risk equation. High excess PHA (HEPHA) was defined as the differences between PHA and chronological age >5 years. Logistic regression models were used to identify factors associated with HEPHA. Age-standardized prevalence of HEPHA was higher in Russia 52%; China 56%; Mexico 59%; and South Africa 65% compared to the US 45%, Ghana 36%; and India 38%. In LMICs, higher income, being divorced/widowed, alcohol intake and abdominal obesity had higher odds of HEPHA; higher education, fruit intake and physical activity had lower odds of HEPHA. The use of PHA may offer a useful avenue to communicate CVD risk. Interventions tailored at socioeconomic and cultural factors that influence CVD risk factors may be necessary to prevent CVD in LMICs.

A systematic review of the associations between HIV/HCV coinfection and biomarkers of cardiovascular disease

The incidence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection has been increasing with over 10 million people affected globally. The role biomarkers play as predictors of cardiovascular disease (CVD) risk among coinfected individuals is not well defined. We aimed to systematically review current evidence describing CVD biomarkers among individuals with HIV/HCV coinfection. We searched EMBASE, CINAHL, Google Scholar, PubMed, and Web of Science from inception to June 2017. MeSH terms and keywords were used to identify studies with information on HIV/HCV coinfection and CVD biomarkers (structural, functional, and serological) such as carotid intima-media thickness (CIMT), endothelial markers, C-reactive protein (CRP), homocysteine, and lipids. Among 332 articles screened, 28 were included (39,498 participants). Study designs varied: 18 cross-sectional, 9 cohort, and 1 clinical trial. Compared with healthy controls and people with HIV or HCV monoinfection, individuals with HIV/HCV coinfection had statistically significant lower levels of lipids and CRP and higher levels of endothelial markers (sICAM-1 and sVCAM-1), CIMT, homocysteine, and IL-6. One study found the odds of carotid plaque in coinfected individuals was 1.64 (0.91-2.94) compared with healthy controls, and another study showed the prevalence of vascular plaques (carotid and femoral) in coinfected individuals was higher compared with HIV monoinfected individuals (44% vs 14%, P = 0.04). Biomarkers of CVD have different patterns of association with HIV/HCV coinfection compared with monoinfection and healthy controls. Prospective studies are needed to confirm the predictive value of these biomarkers for clinical CVD risk among coinfected individuals.

HIV/HCV coinfection and the risk of cardiovascular disease: A meta-analysis

The emergence of improved antiretroviral therapy has increased the life expectancy of human immunodeficiency virus (HIV)-infected individuals, although there is an increased susceptibility to developing cardiovascular diseases (CVD). The risk for CVD is purported to be even higher among people with HIV and hepatitis C virus (HCV) coinfection because of the increased inflammatory response, which may synergistically impact CVD risk. However, studies comparing CVD outcomes between HIV alone and HIV/HCV individuals have been discordant. Accordingly, we conducted a meta-analysis to clarify and quantify the association between HIV/HCV coinfection and the risk for CVD. We searched EMBASE, CINAHL, Google Scholar, PubMed, and Web of Science from inception to December 2016 to identify studies that provided information on HIV/HCV coinfection and CVD, defined as coronary artery disease, congestive heart failure and stroke. We used a random-effects model to abstract and pool data on the hazard ratios (HRs) for CVD. HRs were adjusted for traditional CVD risk factors including age, sex, smoking, hypertension, diabetes and LDL cholesterol. Among the 283 articles reviewed, four cohort studies met inclusion criteria with a total of 33 723 participants. The pooled adjusted HRs for the association between HIV/HCV coinfection and CVD were 1.24 (95% CI: 1.07-1.40) compared to HIV monoinfection. The test for heterogeneity was not statistically significant (I² =0.0%, P=.397). In conclusion, individuals with HIV/HCV coinfection had an increased CVD risk compared to those with HIV monoinfection. More research is needed to further examine the nature of this association, and response to traditional risk-reduction therapies.

Cardiovascular Risk in HIV-Infected and Uninfected Postmenopausal Minority Women: Use of the Framingham Risk Score

OBJECTIVE

To characterize and compare cardiovascular disease (CVD) risk in HIV-infected and uninfected postmenopausal minority women using the Framingham Risk Score (FRS) as an assessment measure.

METHODS

A cross-sectional analysis was performed in 152 (109 HIV+, 43 HIV-) subjects from an existing study cohort of postmenopausal Hispanic and African American women. Data necessary to calculate FRS and menopause features were retrieved by retrospective chart review. Bivariate statistics was used to compare CVD risk factors. Multivariable linear regression was used to determine factors associated with FRS in HIV-infected women.

RESULTS

The HIV-infected group was younger, less obese, and with lower rates of diabetes versus controls. In a subset of age-matched participants, median FRS did not differ between groups (14.6 [IQR = 9.1, 21.6] vs. 15.5 [IQR = 12.3, 22.1]; p = 0.73). Fourteen percent of HIV-infected women meeting criteria for the low-risk FRS category (<10%) had a history of CVD, a similar rate as controls. HIV-infected women at intermediate/high CVD risk had higher rates of surgical menopause. According to 2013 clinical guidelines, more than half of HIV-infected women not prescribed statin therapy (52%) were eligible for treatment; however, statin therapy was similarly under-prescribed in uninfected women.

CONCLUSIONS

In this study, CVD risk as assessed by the FRS was not significantly different by HIV status. Performance of the FRS may be compromised in postmenopausal HIV-infected minority women. HIV-infected and uninfected women may be undertreated with statin therapy. Large longitudinal cohorts and inclusion of subclinical measures of CVD are necessary to better characterize risk.

Hepatitis C virus and cardiovascular: A review

Chronic hepatitis C virus (HCV) infection is a systemic disease that leads to increased risks of cirrhosis and its complications, as well as extrahepatic disturbances, including immune-related disorders and metabolic alterations such as insulin resistance and steatosis. Recent accumulating evidence suggests that HCV infection can increase cardiovascular risk, and that viral eradication can improve cardiovascular outcomes in the clinical setting. These data are strengthened by evidence identifying potential mechanisms (in)directly linking HCV infection to vascular damage. However, the high prevalence of both HCV infection and cardiovascular alterations, as well as the presence of contrasting results not identifying any association between HCV infection and cardiovascular dysfunction, provides uncertainty about a direct association of HCV infection with cardiovascular risk. Further studies are needed to clarify definitively the role of HCV infection in cardiovascular alterations, as well as the impact of viral eradication on cardiovascular outcomes. These features are now more attractive, considering the availability of new, safe, and very effective interferon-free antiviral agents for the treatment of HCV infection. This review aims to discuss carefully available data on the relationship between HCV infection and cardiovascular risk.

Association of injection drug use with incidence of HIV-associated non-AIDS-related morbidity by age, 1995-2014

OBJECTIVE

Incidence of HIV-associated non-AIDS (HANA) related comorbidities is increasing in HIV-infected individuals. Our objective was to estimate the risk of HANA comorbidity associated with history of injection drug use (IDU) correctly accounting for higher death rates among people who inject drugs (PWID).

DESIGN

We followed HIV-infected persons aged 25-59 years who enrolled in the Johns Hopkins HIV Clinical Cohort between 1995 and May 2014, from enrollment until HANA comorbidity diagnosis, death, age 60, or administrative censoring.

METHODS

We compared cumulative incidence ('risk'), by age, of validated diagnoses of HANA comorbidities among HIV-infected PWID and non-IDU; specifically, we considered end-stage renal disease (ESRD), end-stage liver disease (ESLD), myocardial infarction, stroke, and non-AIDS-defining cancer. We used competing risk methods appropriate to account for death, standardized to the marginal distribution of baseline covariates, and adjusted for potential differential loss-to-clinic.

RESULTS

Of 5490 patients included in this analysis, 37% reported IDU as an HIV transmission risk. By age 55 years, PWID had higher risk of ESLD [risk difference = 6.8, 95% confidence interval (CI): -1.9, 15.5] and ESRD (risk difference = 11.1, 95% CI: 1.2, 21.0) than did non-IDU. Risk of myocardial infarction and stroke were similar among PWID and non-IDU. Risk of non-AIDS-defining cancer was lower among PWID than among non-IDU (risk difference at 55 years: -4.9, 95% CI: -11.2, 1.3).

CONCLUSION

Not all HANA comorbidities occur with higher incidence in PWID compared with non-IDU. However, higher incidence of ESRD and ESLD among PWIDs highlights the importance of recognition and management of markers of these comorbidities in early stages among PWID.

Hepatitis C Virus Infection Is Associated With Increased Cardiovascular Mortality: A Meta-Analysis of Observational Studies

BACKGROUND & AIMS

There have been many studies of the effects of hepatitis C virus (HCV) infection on cardiovascular risk, but these have produced ambiguous results. We performed a meta-analysis of these studies to systematically assess the risk of HCV infection on cardiovascular disease (CVD)-related morbidity and mortality.

METHODS

We searched PubMed Central, Medline, Embase, and Cochrane Library, as well as reference lists of articles, for studies published through July 2015 that compared the occurrence of CVD between HCV-infected and HCV-uninfected subjects, or assessed the prevalence of HCV infection among subjects with CVDs. In total, 22 studies were analyzed. Data on the patient populations and outcomes were extracted from each study by 3 independent observers and combined by a random-effects model.

RESULTS

Compared with uninfected individuals (controls), HCV-infected patients had increased risks of CVD-related mortality (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.07-2.56; P = .02), carotid plaques (OR, 2.27; 95% CI, 1.76-2.94; P < .001), and cerebrocardiovascular events (OR, 1.30; 95% CI, 1.10-1.55; P = .002). Significant heterogeneity was observed in the risk of cerebrocardiovascular disease among individuals with HCV infection. The effect of HCV infection on cerebrocardiovascular disease was stronger in populations with a higher prevalence of diabetes (>10%) or hypertension (>20%) (OR, 1.71; 95% CI, 1.32-2.23; P < .001 for both).

CONCLUSIONS

In a meta-analysis of published studies, individuals with HCV infections were found to be at increased risk for CVD-related morbidity and mortality-especially patients with diabetes and hypertension.

Assessment of cardiovascular risk factors in people with HIV infection treated with ART in rural South Africa: a cross sectional study

BACKGROUND

The risk of cardiovascular diseases (CVD) in human immunodeficiency virus (HIV) infected people on antiretroviral therapy (ART) from some rural parts of Africa is not well known. We assessed CVD risk factors, the estimated 5-year Data collection on adverse effects of anti-HIV drugs (DA.) risk score and the 10-year Framingham risk score in persons with HIV infection on ART in a rural area in South Africa.

METHODS

A cross-sectional study in which the data on demographic, lifestyle, and chronic disease were collected using the World Health Organization Stepwise approach to surveillance questionnaire. Biochemical parameters were tested using standard biochemical methods. CD4 counts were performed using PIMA analyser and viral load was tested using the branched deoxyribonucleic acid technique. Student t test and Chi square test were used on continuous and categorical variables respectively. Bivariate and multivariate logistic regression were used to analyze predictors of CVD risk factors. Estimates of 5 and 10-year CVD risk were calculated using online tools. The Cohen's kappa coefficient was used to assess the agreement between CVD risk equations.

RESULTS

The mean age of participants was 44.8 ± 11.8 years; 79.9 % were females. Most of the participants (85 %) had an undetectable viral load and a mean CD4 count of 462 ± 235 cell/mm(3). The most common CVD risk factors were low high density lipoprotein cholesterol (HDL-C) (43.8 %), hypercholesterolaemia (33.2 %) and a high Apolipoprotein (Apo) B/ApoA ratio (45.4 %).Using the Framingham equation, 6.7 % of participants had a moderate to high 10-year CVD risk while the DAD risk equation showed that 31.1 % of participants had a moderate to high 5-year CVD risk. Most participants had a low CVD risk by both risk equations. The level of agreement between the two risk equations was 73.8 % (k = 0.23; 95 % CI 0.10-0.35; p value 0.001).

CONCLUSION

CVD risk factors were common among this rural population on ART. The high proportion of participants with a moderate to high CVD risk, observed with the DAD risk equation, clearly represents a considerable health burden that can possibly be reduced by increasing educational programs on CVD prevention for people on ART. There is however a need to develop and evaluate a race/ethnicity-specific CVD risk estimation tool for HIV infected Africans.

Vascular and Chronological Age in Subjects with Erectile Dysfunction: A Cross-Sectional Study

INTRODUCTION

Vascular age, as derived from the SCORE project algorithm for cardiovascular (CV) risk estimation, is an effective way for communicating CV risk. However, studies on its clinical correlates are scanty.

AIM

To evaluate if the difference between vascular and chronological age (Δage), in a population of subjects with erectile dysfunction (ED), can identify men with a worse risk profile.

METHODS

A consecutive series of 2,853 male patients attending the outpatient clinic for erectile dysfunction (ED) for the first time was retrospectively studied. Among them, 85.4% (n = 2,437) were free of previous MACE and were analyzed.

MAIN OUTCOME MEASURES

Several clinical, biochemical, and penile color Doppler parameters were studied. Vascular age was derived from the SCORE project algorithm, and the Δage was considered.

RESULTS

Higher Δage is associated with several conventional (family history of CV diseases, hyperglycemia, elevated triglycerides, and increased prevalence of metabolic syndrome) and unconventional (severity of ED, frequency of sexual activity, alcohol abuse, lower education level, fatherhood, extramarital affairs, compensated hypogonadism, and low prolactin levels) risk factors. Δage is inversely related to penile color Doppler parameters, including flaccid and dynamic peak systolic velocity and flaccid acceleration (β = -0.125, -0.113, and -0.134, respectively, all P < 0.0001).

CONCLUSIONS

In subjects referring for ED without a personal history of CV events, Δage is associated with an adverse cardio-metabolic profile and worse penile color Doppler ultrasound parameters. Δage provides a simple method for identifying high-risk men that must undergo significant modification in their lifestyle and risk factors. In addition, it can be considered a simple, inexpensive, and safe surrogate marker of penile arterial damage.

Fibroblast growth factor 23: associations with antiretroviral therapy in patients co-infected with HIV and hepatitis C

OBJECTIVES

Fibroblast growth factor 23 (FGF23) has been associated with cardiovascular mortality. We estimate associations between the level of plasma FGF23 and exposure to abacavir (ABC) and to other components of antiretroviral therapy in patients co-infected with HIV and hepatitis C.

METHODS

Both intact and c-terminal FGF23 were measured in plasma using commercial assays for a sub-cohort of 295 patients selected at random from the 1150 patients enrolled in the Canadian Co-infection Cohort. The multiplicative effects of antiretroviral drug exposures and covariates on median FGF23 were then estimated using a hierarchical Bayesian model.

RESULTS

The median level of intact FGF23 was independent of either past or recent exposure to abacavir, with multiplicative ratios of 1.00 and 1.07, 95% credible intervals 0.90-1.12 and 0.94-1.23, respectively. Median intact FGF23 tended to increase with past use of both nonnucleoside reverse-transcriptase inhibitors and protease inhibitors, but tended to decrease with recent use of either tenofovir, efavirenz or lopinavir. There were no obvious associations between the median level of c-terminal FGF23 and individual drugs or drug classes. Age, female gender, smoking and the aspartate aminotransferase to platelet ratio index were all associated with a higher median c-terminal FGF23 but not with a higher median intact FGF23.

CONCLUSIONS

The level of FGF23 in plasma was independent of exposure to ABC. Lower levels of intact FGF23 with recent use of tenofovir, efavirenz or lopinavir may reflect their adverse effects on bone and vitamin D metabolism relative to other drugs in their respective drug classes.

Vascular age to determine cardiovascular disease risk: A systematic review of its concepts, definitions, and clinical applications

BACKGROUND

Vascular age is an alternate means of representing an individual's cardiovascular risk. Little consensus exists on what vascular age represents and its clinical utility has not been determined. We systematically reviewed the literature to provide a comprehensive overview of different methods that have been used to define vascular age, and to examine its potential clinical value in patient communication and risk prediction.

DESIGN

This was a systematic review with data sources of PubMed and Embase.

RESULTS

We identified 39 articles on vascular age, 20 proposed to use vascular age as a communication tool and 19 proposed to use vascular age as a means to improve cardiovascular risk prediction. Eight papers were methodological and 31 papers reported on vascular age in study populations. Of these 31 papers, vascular age was a direct translation of the absolute risk estimated by existing cardiovascular risk prediction models in 15 papers, 12 derived vascular age from the reference values of an additional test, and in three papers vascular age was defined as the age at which the estimated cardiovascular risk equals the risk from non-invasive imaging observed degree of atherosclerosis. One trial found a small effect on risk factor levels when vascular age was communicated instead of cardiovascular risk.

CONCLUSION

Despite sharing a common name, various studies have proposed distinct ways to define and measure vascular age. Studies into the effects of vascular age as a tool to improve cardiovascular risk prediction or patient communication are scarce but will be required before its clinical use can be justified.

HCV, but not HIV, is a risk factor for cerebral small vessel disease

OBJECTIVES

With the aging of HIV populations, vascular contributions to neuropathogenesis are increasingly important. Indirect analyses of cerebral small vessel disease have been performed, but there have been no direct studies of human brain to elucidate risk factors for arteriolar sclerosis.

METHODS

Mean arteriolar wall thickness (sclerotic index, SI) was measured in the deep cerebral white matter of 126 brains (96 HIV+, 30 HIV-). Correlations with SI were performed for age, sex, race, hypertension, hyperlipidemia, diabetes, obesity, cirrhosis, hepatitis C virus (HCV) infection, herpes infection, HIV infection, HIV risk, cocaine use, CD4 count, plasma HIV load, and combination antiretroviral therapy (cART) at the time of death.

RESULTS

Age, hypertension, race, HCV, and cirrhosis were associated with SI; of the HIV variables, only cART at death was associated with SI. To address colinearity, partial correlations were run with HCV and cirrhosis, hypertension and race, and hypertension and age. With HCV controlled, cirrhosis lost significance; with hypertension controlled, age lost significance. For the entire sample, HCV, African American race, and hypertension accounted for 15% of SI variance in multivariate analysis. Each was independently associated with SI, and HCV had the largest effect. For the HIV sample, inclusion of cART in the model increased R (2) to 0.205, with only HCV, hypertension, and cART remaining significant or trend level.

CONCLUSIONS

This tissue-based analysis of cerebral arteriolar disease demonstrates that HCV constitutes an independent risk, in addition to African American race, hypertension, and cART. Further study is needed to understand what aspects of HCV and cART contribute to cerebrovascular neuropathogenesis.

Is hepatitis C associated with atherosclerotic burden? A systematic review and meta-analysis

BACKGROUND AND AIMS

Increasing evidence demonstrates that hepatitis C virus (HCV) infection is associated with atherosclerosis. However, there are contrasting findings in several studies that the atherosclerotic burden is not associated with HCV infections. Therefore, we performed a meta-analysis to clarify if HCV infection is associated with atherosclerosis compared to non-infected people.

METHODS

Standard guidelines for performance of meta-analysis were followed.

RESULTS

A thorough database search performed by two independent investigators identified 14 eligible studies for analysis. The data from 11 studies were synthesized to report unadjusted odds ratios (ORs) for carotid atherosclerosis; the pooled unadjusted OR (95% confidence interval (CI)) was 1.65 (1.21, 2.09). By synthesizing the data from 8 studies to report adjusted ORs for carotid atherosclerosis the pooled multi-confounder adjusted OR (95% CI) was 1.76 (1.20, 2.32). However, the numbers of studies on coronary or femoral atherosclerosis were limited and not enough for analysis.

CONCLUSIONS

Our meta-analysis indicates that HCV infection is associated with carotid atherosclerosis independent of classical risk factors. Therefore, we would recommend for HCV infected patients to be counseled on their risk for carotid atherosclerosis.

Metabolic syndrome, diabetes, and cardiovascular risk in HIV

HIV infection and its treatment have been associated with adipose tissue changes and disorders of glucose and lipid metabolism. The proportion of HIV-infected adults over the age of 50 is also growing placing HIV-infected adults at particular risk for metabolic perturbations and cardiovascular disease. The metabolic syndrome in HIV-infected adults has been increasingly studied but whether HIV is associated with greater risk remains unclear, likely because of the interplay of host, viral and antiretroviral factors that are associated with the components of the metabolic syndrome. The relationship between HIV and diabetes mellitus (DM) risk has also been debated. While the Framingham Risk Score is a well-accepted measure of 10-year cardiovascular risk in the general population, it may not accurately predict risk in the HIV setting due to HIV-related factors such as inflammation that are not accounted for. We summarize the recent literature on metabolic syndrome, DM, and cardiovascular risk in HIV-infected adults.

Recent advances on hepatitis C virus in dialysis population

Hepatitis C virus (HCV) infection remains common among patients undergoing regular dialysis and good evidence supports the detrimental role of HCV on survival in patients undergoing maintenance dialysis. According to an updated meta-analysis of clinical studies (n=15; 195,370 unique patients on maintenance dialysis), the summary estimate for adjusted relative risk (all-cause mortality) with anti-HCV across the published studies was 1.32 with a 95% Confidence Intervals of 1.24; 1.42, homogeneity assumption was not rejected. Various mechanisms support the excess death risk of HCV-infected patients on regular dialysis, in addition to liver disease-related mortality. The adjusted relative risk for cardiovascular mortality among HCV-infected patients on regular dialysis was 1.26 (95% Confidence Intervals, 1.10; 1.45); the increased cardiovascular mortality in anti-HCV positive patients has been associated in part to malnutrition and chronic inflammation. The current standard of care for HCV in dialysis population is combined antiviral therapy (pegylated interferon plus ribavirin) with a rate of viral response of around 60%. Triple therapy with telaprevir proved to be effective and safe in dialysis patients with HCV but only anecdotal evidence exists. Antiviral treatment of HCV-infected patients on maintenance dialysis could lead to cure the liver damage and the extrahepatic complications. The future availability of all-oral interferon/ribavirin free regimens for antiviral treatment of HCV will help nephrologists to improve survival in this high-risk group.

Thromboembolic events among patients with hepatitis C virus infection and cirrhosis: a matched-cohort study

INTRODUCTION

Portal vein thrombosis is a known risk among patients with cirrhosis, but the incidence of other thromboembolic events among patients with liver disease is inadequately delineated. This study examined the incidence of venous and arterial thromboembolic events in patients with cirrhosis and hepatitis C virus (HCV) infection and matched comparators.

METHODS

Patients diagnosed with HCV or cirrhosis of various etiologies were identified from a large medical claims database and matched by age and sex to comparator cohorts. New-onset diagnoses of venous and arterial thromboembolic events were determined. The incidence rate of each event was calculated and rate ratios computed using Poisson regression models, adjusting for baseline factors.

RESULTS

The study included 22,733 HCV-infected patients and 68,198 comparators, and 15,158 cirrhosis patients and 45,473 comparators. The incidence of any thromboembolic event was 233.4 events per 10,000 person-years for the HCV cohort and 138.5 per 10,000 person-years for the comparators; the adjusted incidence rate ratio for any thromboembolic event was 1.62 (95% confidence interval [CI]: 1.48-1.77). For the cirrhosis patients and comparators, the crude rates of any thromboembolic event were 561.1 and 249.7 per 10,000 person-years, respectively. The adjusted incidence rate ratio was 2.28 (95% CI: 2.11-2.47). Arterial events, especially unstable angina and transient ischemic attack, were the most frequent events seen in both the HCV and cirrhosis cohorts, but venous events, especially portal vein thrombosis, showed a more pronounced elevation in patients with liver disease.

CONCLUSIONS

Patients with HCV and cirrhosis of various etiologies are at increased risk of several types of thromboembolic events. Physicians should consider this increased risk when managing patients with liver disease.

Identifying the appropriate comparison group for HIV-infected individuals

PURPOSE OF REVIEW

HIV-infected individuals are living longer as a result of effective treatment. Age-related comorbidities now account for the majority of morbidity and mortality among treated HIV-infected adults. Previous findings regarding the age at, and risk of, these comorbidities have been mixed, sparking debate in the field. Discerning potential differences in the occurrence and burden of age-related comorbidities among treated HIV-infected adults as compared with uninfected adults of the same age requires careful selection of the appropriate uninfected comparison group.

RECENT FINDINGS

The validity of comparisons with HIV-uninfected populations is threatened when differences in demographic, clinical, and lifestyle characteristics between HIV-infected and uninfected adults are not considered. Identifying a pool of HIV-uninfected individuals from existing secondary data resources and employing selection methodologies may be a novel approach to reduce threats to internal validity. Issues related to identifying data sources, understanding inclusion criteria, determining measurement error, and threats to inference are discussed.

SUMMARY

The development of clinical interventions targeting age-related comorbidities will rely on deriving valid inferences from appropriate comparison groups. The use of secondary data resources and selection methodology to create the appropriate uninfected comparison group is an attractive approach in the setting of finite resources, but are not without limitations.

Differences in outpatient care and treatment utilization for patients with HIV/HCV coinfection, HIV, and HCV monoinfection, a cross-sectional study

BACKGROUND

Few studies have explored how utilization of outpatient services differ for HIV/HCV coinfected patients compared to HIV or HCV monoinfected patients. The objectives of this study were to (1) compare annual outpatient clinic visit rates between coinfected and monoinfected patients, (2) to compare utilization of HIV and HCV therapies between coinfected and monoinfected patients, and (3) to identify factors associated with therapy utilization.

METHODS

Data were from the 2005-2010 U.S. National Hospital Ambulatory Medical Care Surveys. Clinic visits with a primary or secondary ICD-9-CM codes for HIV or HCV were included. Coinfection included visits with codes for both HIV and HCV. Monoinfection only included codes for HIV or HCV, exclusively. Patients <15 years of age at time of visit were excluded. Predictors of HIV and HCV therapy were determined by logistic regressions. Visits were computed using survey weights.

RESULTS

3,021 visits (11,352,000 weighted visits) met study criteria for patients with HIV/HCV (8%), HIV (70%), or HCV (22%). The HCV subgroup was older in age and had the highest proportion of females and whites as compared to the HIV/HCV and HIV subgroups. Comorbidities varied significantly across the three subgroups (HIV/HCV, HIV, HCV): current tobacco use (40%, 27%, 30%), depression (32%, 23%, 24%), diabetes (9%, 10%, 17%), and chronic renal failure (<1%, 3%, 5%), (p < 0.001 for all variables). Annual visit rates were highest in those with HIV, followed by HIV/HCV, but consistently lower in those with HCV. HIV therapy utilization increased for both HIV/HCV and HIV subgroups. HCV therapy utilization remained low for both HIV/HCV and HCV subgroups for all years. Coinfection was an independent predictor of HIV therapy, but not of HCV therapy.

CONCLUSION

There is a critical need for system-level interventions that reduce barriers to outpatient care and improve uptake of HCV therapy for patients with HIV/HCV coinfection.

Towards hepatitis C eradication from the HIV-infected population

Around 10-15% of the 35 million people living with HIV worldwide have chronic hepatitis C virus (HCV) infection and are prone to develop liver-related complications. Exposure to HCV is almost universal among injecting drug users and is on the rise among homosexual men. Response to peginterferon-ribavirin therapy is generally lower in coinfection compared to HCV monoinfection. For this reason, the advent of direct-acting antivirals (DAA) is eagerly awaited for this population. The results of trials using DAA in coinfection show that treatment response rates are similar to those obtained in HCV monoinfection. Thus, HIV should no longer be considered as a "special" population, as long as antiretroviral therapy is given and drug interactions are taken into account. Envisioning HCV eradication from the HIV population faces major challenges ahead, including identification of the large number of undiagnosed individuals, and ensuring wide access to the best but often expensive HCV medications. This article forms part of a symposium in Antiviral Research on "Hepatitis C: next steps toward global eradication".

Mortality among persons in care with hepatitis C virus infection: the Chronic Hepatitis Cohort Study (CHeCS), 2006-2010

BACKGROUND

The number of deaths in hepatitis C virus (HCV)-infected persons recorded on US death certificates has been increasing, but actual rates and causes of death in these individuals have not been well elucidated.

METHODS

Disease-specific, liver-related, and non-liver-related mortality data for HCV-infected patients in an observational cohort study, the Chronic Hepatitis Cohort Study (CHeCS) at 4 US healthcare systems, were compared with multiple cause of death (MCOD) data in 12 million death certificates in 2006-2010. Premortem diagnoses, liver biopsies, and FIB-4 scores (a noninvasive measure of liver damage) were examined.

RESULTS

Of 2 143 369 adult patients seen at CHeCS sites in 2006-2010, 11 703 (0.5%) had diagnosed chronic HCV infection, and 1590 (14%) died. The majority of CHeCS decedents were born from 1945 to 1965 (75%), white (50%), and male (68%); mean age of death was 59 years, 15 years younger than MCOD deaths. The age-adjusted mortality rate for liver disease in CHeCS was 12 times higher than the MCOD rate. Before death, 63% of decedents had medical record evidence of chronic liver disease, 76% had elevated FIB-4 scores, and, among those biopsied, 70% had moderate or worse liver fibrosis. However, only 19% of all CHeCS decedents and only 30% of those with recorded liver disease had HCV listed on their death certificates.

CONCLUSIONS

HCV infection is greatly underdocumented on death certificates. The 16 622 persons with HCV listed in 2010 may represent only one-fifth of about 80 000 HCV-infected persons dying that year, at least two-thirds of whom (53 000 patients) would have had premortem indications of chronic liver disease.

Hepatitis C in 2013: HCV causes systemic disorders that can be cured

Successful treatment with antivirals reduces the incidence of some extrahepatic manifestations of HCV. Thus, the advent of well-tolerated and highly potent antiviral regimens might enable extension of the indication for therapy to patients at risk of developing serious extrahepatic disorders, irrespective of the severity of the underlying liver disease.