Cardiovascular Disease Burden in Rural Africa: Does HIV and Antiretroviral Treatment Play a Role?: Baseline Analysis of the Ndlovu Cohort Study

The Association Between HIV-Related Stigma, ART Adherence, and Cardiovascular Disease Risk in People Living With HIV

INTRODUCTION

HIV/AIDS continues to be a significant health issue in sub-Saharan Africa, with stigma likely affecting ART adherence, and subsequently viremia, inflammation, and cardiovascular disease (CVD). We investigated the association between stigma, ART adherence, and CVD risk among people living with HIV (PLWH).

SETTING

A longitudinal study was conducted among 325 PLWH from the Ndlovu Cohort Study, South Africa.

METHODS

Stigma was assessed using a 12-item questionnaire (range: 0-44; higher scores indicate greater stigma). Pulse wave velocity (PWV, CVD surrogate marker) and viral load (VL) were assessed at 12 and 36 months. VL was considered a surrogate marker of ART adherence: VL > 1000 copies indicating poor/no adherence, VL 50-1000 copies suboptimal, and VL < 50 copies good adherence. The relationship between stigma, VL, and PWV was assessed by linear regression and changes in PWV overtime by mixed linear models.

RESULTS

At baseline, PLWH (n = 325, mean age (SD) = 41.1 (10.2) years, 67% female) had mean PWV of 7.3 min/s. Good, suboptimal, and poor adherence were 78%, 15%, and 7%, respectively. The mean (SD) stigma score was 16.9 (1.4) and was not associated with VL and PWV. Suboptimal and poor adherence were associated with higher PWV [beta = 4.18 (95% confidence interval (CI): 1.79 to 6.57)] at 12 months and between 12 and 36 months [beta = 1.30 (95% CI: 0.06 to 2.55)] in mixed model analyses in PLWH older than 49 years, respectively. PWV increased by 0.21 min/s (95% CI: 0.02 to 0.40; P = 0.03) between 12 and 36 months overall.

CONCLUSIONS

In this study, poor ART adherence was associated with higher PWV. The stigma score was low and not associated with ART adherence and PWV.

The association of HIV status and depressive symptoms in the Ndlovu Cohort study

HIV majorly contributes to the disease burden in South Africa. Depressive symptoms are common in people living with HIV (PLHIV). Few studies compared depressive symptoms between PLHIV and those without HIV. The aim of the study was to examine the association of HIV status and depressive symptoms. Moreover, the study aimed to explore the comparison between HIV-negative participants and the different HIV-positive sub-groups regarding their depressive symptoms. A cross-sectional analysis was conducted among PLHIV and HIV-negative participants in rural South Africa, using the baseline data of the Ndlovu Cohort study. Data was collected on demographics, socioeconomic status, and depressive symptoms using the PHQ-9 questionnaire. A score of 10 and above indicated depressive symptoms. Logistic regression analysis on the relationship between HIV status and depressive symptoms was used while adjusting for age, sex, level of education, employment status, income, and ever smoking. The study included 1,927 participants; 46% were PLHIV and 239 (12.5%) had depressive symptoms. PLHIV were more likely to have depressive symptoms than HIV-negative participants (OR 1.34, 95% CI 1.01-1.77). This association was not statistically significant after adjusting for confounders (OR 1.22, 95% CI 0.92-1.63). Compared to HIV-negative participants, ART (antiretroviral treatment) naïve participants had statistically significant higher odds of depressive symptoms (OR 1.84, 95% CI 1.20-2.78). This association remained after adjusting for confounders (OR 1.72, 95% CI 1.11-2.61). There was no statistically significant difference in depressive symptoms between HIV-negative participants and those on ART, regardless of treatment regimen. In general, higher odds of depressive symptoms in ART-naïve PLHIV could reflect poor coping with diagnosis of HIV. Future research to investigate the relation between ART regimen and depressive symptoms, to establish causality and to identify changes over time, is warranted.

A Comprehensive Review of the Manifestation of Cardiovascular Diseases in HIV Patients

The increasing lifespan of people living with HIV (PLWH) due to advancements in antiretroviral therapy (ART) has shifted mortality patterns from AIDS-related to non-AIDS-related causes, notably cardiovascular diseases (CVDs). This review investigates how HIV and ART contribute to vascular endothelial dysfunction, myocardial fibrosis, and hypercoagulation, which significantly exacerbate cardiovascular risk. Mechanistic insights include chronic inflammation and immune dysregulation due to persistent HIV infection and ART-specific effects such as protease inhibitors causing dyslipidemia and zidovudine inducing mitochondrial toxicity leading to cardiomyopathy. ART, while lifesaving, has been implicated in promoting subclinical atherosclerosis and increasing the risk of acute myocardial infarction, further highlighting the need for tailored approaches. The manuscript addresses pressing obstacles, including disparities in healthcare access and the lack of standardized cardiovascular screening guidelines specific to PLWH. It emphasizes the integration of advanced imaging techniques and emerging biomarkers, such as coronary artery calcium scoring and soluble ST2, to detect early subclinical cardiovascular abnormalities. The review also identifies challenges in ART selection to balance virologic control and cardiovascular safety. What sets this review apart is its holistic and detailed approach to the intersection of HIV and cardiovascular health. It not only elucidates complex pathophysiological mechanisms but also offers actionable insights into how current clinical guidelines fall short. This manuscript underscores the urgency of implementing proactive cardiovascular screening protocols tailored for PLWH and refining ART regimens to mitigate CVD risks. By addressing these gaps, this work aims to expand our understanding of HIV-related cardiovascular manifestations and provide a foundation for targeted interventions, thereby improving long-term health outcomes for PLWH. This comprehensive perspective is poised to transform clinical practice by fostering greater awareness among physicians and encouraging the development of more effective strategies for managing cardiovascular risks in the HIV population.

Lack of impact of HIV status on carotid intima media thickness in a cohort of stroke patients in South Africa

INTRODUCTION

People living with HIV (PLWH) are at increased risk for cardiovascular disease. Carotid intima media thickness (cIMT) is a validated surrogate marker of atherosclerosis, and an accurate predictor of future cardiovascular events. It is uncertain whether HIV potentiates stroke risk through atherosclerosis in Sub-Saharan Africa and what effect HIV status has on cIMT. We sought to investigate the relationship between HIV status and cIMT in stroke patients in a region that is burdened with dual epidemics of HIV and stroke in the young.

METHODS

Consecutive patients with new onset ischaemic stroke were recruited from a quaternary-level hospital in Johannesburg, South Africa, from August 2014 to November 2017. Patients were assessed for the presence of traditional cardiovascular risk factors and HIV infection, and investigated for stroke aetiology. cIMT was measured using high resolution B-mode ultrasound following standardized techniques.

RESULTS

168 patients were included in the study, of which 62 (36.9%) were PLWH. Mean cIMT was higher in HIV-uninfected patients when compared to PLWH (0.79 ± 0.19 mm vs 0.69 ± 0.18 mm, p = 0.0021). However after adjusting for age, sex, hypertension, diabetes mellitus, smoking, total cholesterol, body mass index and stroke aetiology, there was no difference in mean cIMT between the groups (0.76 ± 0.16 mm vs 0.73 ± 0.17 mm, p = 0.29). Regression models revealed the determinants of cIMT to be age (p < 0.0001), hypertension (p = 0.0098) and total cholesterol (p = 0.005), while the determinants of increased cIMT (≥0.70 mm) were only age (p < 0.0001) and hypertension (p = 0.0002).

CONCLUSION

HIV status had no effect on cIMT in our cohort of stroke patients. The main determinants of cIMT were age and hypertension.

No Evidence for an Association of HIV and Antiviral Treatment With Changes in Framingham Cardiovascular Risk Score in the Ndlovu Cohort Study

BACKGROUND

HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease (CVD) risk in high-income countries. The authors studied the longitudinal association between HIV and ART and nonlaboratory Framingham Risk Score (FRS) in a middle-income country.

METHODS AND RESULTS

This longitudinal analysis of the NCS (Ndlovu Cohort Study), South Africa used baseline to 36-month follow-up data. Demographics, HIV, ART status, and cardiometabolic measures were obtained. FRS was used as a CVD risk measure. Through linear mixed models, FRS trends over time and the association with HIV were studied. Analysis included 1136 participants, with 609 (54%) having HIV, and 495 (81%) taking ART. At baseline, 9.8% of participants had a high FRS. People living with HIV (PLHIV) had a 3.2% lower FRS than HIV-negative participants (P<0.001). FRS increased similarly for both groups over time. Other factors associated with FRS were secondary and higher education (ß value: -0.075, P<0.001; ß value: -0.084, P<0.001) and alcohol consumption (ß value: 0.011, P<0.001).

CONCLUSIONS

CVD risk increased for all participants over 36 months, suggesting classic risk factors rather than HIV status or ART to be drivers of CVD risk. People living with HIV had a significantly lower FRS than their HIV-negative counterparts, possibly related to HIV itself or a more frequent interaction with healthcare services. No association of HIV and ART with changes in FRS over 36 months was observed, suggesting the need for research using clinical endpoints to elucidate the effects of HIV and ART on CVD risk. Population-based prevention of CVD risk factors in sub-Saharan Africa is warranted, regardless of HIV status.

HIV Infection and 90-Day Stroke Outcomes in Uganda: A Prospective Observational Cohort Study

Background and Objectives

Little is known about the impact of HIV infection on the clinical presentation and outcomes after stroke in the modern antiretroviral therapy (ART) era. We aimed to compare stroke characteristics and outcomes between persons with HIV (PWH) and without HIV (PWOH) presenting with stroke in Uganda.

Methods

We conducted a matched cohort study at Mulago National Referral Hospital and Mbarara Regional Referral Hospital between January 2018 and November 2020. We enrolled consecutive PWH presenting with CT-confirmed acute or subacute stroke (symptom onset ≤14 days) and matched them by sex and stroke type to 2 consecutive available PWOH admitted to the same hospital. We obtained baseline clinical data and followed participants for 90 days from the day of clinical presentation. We compared stroke severity (defined by the NIH stroke scale [NIHSS]) and 90-day all-cause mortality and morbidity (using the modified Rankin Scale [mRS]) by HIV serostatus with and without adjustment for confounders.

Results

We enrolled 105 PWH and 157 PWOH with stroke. PWH were younger (mean [SD] age 49 [14] vs 59 [16] years, p < 0.001), and nearly 80% (82/105) were on ART for a median of 5 years and a median CD4 count of 214 cells/uL (interquartile range 140, 337). Compared with PWOH, PWH presented with a 3-point lower median NIHSS (16 vs 19, p = 0.011), a 20% lower proportion of all-cause mortality at 90 days (p = 0.001), and had less disability at 90 days (median mRS 4 vs 5, p = 0.004). Age and NIHSS-adjusted odds ratio of 90-day all-cause mortality in PWH compared with PWOH was 0.45 (95% CI 0.22-0.96, p = 0.037).

Discussion

In the modern ART era, PWH with acute stroke in Uganda present with modest stroke and are significantly less likely to die within 90 days than PWOH. This potentially reflects the protective effects of ART, enhanced health care access, and their younger age at stroke presentation.

Pharmacotherapeutic profile, polypharmacy and its associated factors in a cohort of people living with HIV in Brazil

BACKGROUND

The increased survival provided by the access, development, and evolution of antiretroviral drugs (ARV) greatly increased the life expectancy of people living with HIV (PWH). This has also led to an increased occurrence of diseases or morbidities related to aging. In individuals with multiple comorbidities, the simultaneous use of multiple medications, also known as polypharmacy, is common, and rational use of medications is essential. This study aims to describe the pharmacotherapeutic profile, estimate the prevalence of polypharmacy and identify factors associated with polypharmacy in a cohort of adult PWH from a referral unit in Rio de Janeiro, Brazil.

METHODS

Cross-sectional study including PWH on ARV who received at least one medical prescription (outpatient/hospitalized) in 2019. We described the proportion of prescribed medications according to ARV and Anatomical Therapeutic Chemical (ATC) classes stratified by age (< 50 vs. ≥50 years). Polypharmacy was defined as ≥ 5 medications prescribed beyond ARV. Logistic regression models assessed demographic and clinical factors associated with polypharmacy.

RESULTS

A total of 143,306 prescriptions of 4547 PWH were analyzed. Median age was 44.4 years (IQR:35.4-54.1) and 1615 (35.6%) were ≥ 50 years. A total of 2958 (65.1%) participants self-identified as cisgender man, 1365 (30.0%) as cisgender woman, and 224 (4.9%) as transgender women. Most self-declared Black/Pardo (2582; 65.1%) and 1984 (44.0%) completed elementary education or less. Median time since HIV diagnosis was 10.9 years (IQR:6.2-17.7). Most frequently prescribed concomitant medications were nervous system (64.8%), antiinfectives for systemic use (60.0%), alimentary tract and metabolism (45.9%), cardiovascular system (40.0%) and respiratory system (37.1%). Prevalence of polypharmacy was 50.6% (95%CI: 49.2-52.1). Model results indicated that being older, self-identify as cisgender woman, having less education and longer time since HIV diagnosis increased the odds of polypharmacy.

CONCLUSIONS

We found high rates of polypharmacy and concomitant medication use in a cohort of PWH in Brazil. Targeted interventions should be prioritized to prevent interactions and improve treatment, especially among individuals using central nervous system and cardiovascular medications, as well as certain groups such as cisgender women, older individuals and those with lower education. Standardized protocols for continuous review of patients' therapeutic regimens should be implemented.

Metabolic Syndrome in HIV: Prevalence, correlates, concordance of Diagnostic Criteria and relationship to Carotid Intimal Media Thickness in a Sub-Saharan Population

Background

The prevalence and usefulness of MetS in determining CVD risk in at-risk populations are influenced by its definition. In a cohort of HIV-positive Nigerians, we evaluated MetS based on various defining criteria, their agreement with one another, and their association to a CVD endpoint, Carotid-Intimal-Media-Thickness (CIMT).

Methodology

In this cross-sectional study, 145 HIV-positive individuals who were enrolled in HIV clinics at the Faith Alive Foundation and Jos University Teaching Hospital in Jos, Nigeria, were randomly chosen. Biophysical and anthropometric measurements including blood pressure, height, weight, waist circumference, and hip-circumference, as well as clinical records, CIMT, fasting plasma glucose, and lipid profile, were assessed.

Result

The median (Interquartile range) age of the participants was 41 (35-88) years, and the majority (71.7%) were females. The prevalence of metabolic syndrome (MetS) by the Adult Treatment Panel-III (ATP), International Diabetes Federation (IDF), and Joint Interim Statement (JIS) criteria were 30.3%, 32.4%, and 35.2% respectively. MetS by all criteria was more prevalent among females and participants ≥ 40 years, p<0.05. Low HDLc (93.6-95.5%), Central obesity (86.3-95.5%), and hypertension (80.9-86.4%) were the most frequent components of MetS. HIV-related parameters were not associated with MetS. The overall agreement among MetS criteria was almost perfect between IDF and JIS criteria (k=0.94); and strong between IDF vs., ATP (k=0.82) and ATP vs. JIS (k=0.89). There was no significant difference in the median CIMT in PLHIV with and without MetS across all defining criteria.

Conclusion

The prevalence of MetS in PLHIV is relatively high, particularly among females and older individuals. The correlations between the defining criteria were fairly strong and consistent across subpopulations of PLHIV. MetS based on these criteria, however, do not significantly correlate with rising CIMT.

Prevalence and risk factors for subclinical atherosclerosis amongst adults living with HIV in University of Abuja Teaching Hospital, Gwagwalada

Background

Subclinical atherosclerosis characterizes cardiovascular diseases (CVD), and Human Immunodeficiency Virus (HIV) infection and antiretroviral therapy (ART) are identified risk factors for atherosclerosis. Meanwhile, data on HIV and atherosclerosis in Nigeria are limited.

Objectives

We sought to estimate the prevalence of subclinical atherosclerosis and associated risk factors amongst adult persons living with HIV/AIDS (PLHIV) enrolled at University of Abuja Teaching Hospital, Gwagwalada, Abuja (UATH).

Methods

This was a cross-sectional study of 277 consecutively selected PLHIV ≥18 years enrolled for HIV care and treatment at UATH. Pretested structured questionnaire was used to collect data from consenting ART-experienced and ART-naïve patients on risk factors of atherosclerosis. Carotid intima media thickness (CIMT) ≥0.71 mm as measured by Doppler ultrasonography was used to identify patients with sub-clinical atherosclerosis. Two logistic regression models with (Model-A) and without (Model-B) traditional risk factors were fitted to identify risk factors of subclinical atherosclerosis.

Results

Participants' mean age was 39.44 ± 10.71 years with female preponderance (64.26%). Overall prevalence of subclinical atherosclerosis was 43.32% (62.25% in ART-experienced). Model-A identified male sex [AOR 4.33(1.74-10.76), p = 0.002], advancing age [30-39 years AOR 5.95(1.31-26.96), p = 0.021]; ≥40 years AOR 19.51(4.30-88.56), p ≤ 0.001), advancing HIV infection [≥WHO stage II AOR 4.19(1.11-15.92), p = 0.035], hypercholesterolemia [AOR 3.88(1.47-10.25), p ≤ 0.001] and ≥5 year duration on ART [AOR 9.05(3.16-25.92), p ≤ 0.001] as risk factors of subclinical atherosclerosis. In Model-B (excluding traditional risk factors) on the other hand, advancing HIV infection [≥WHO stage II AOR 3.93(1.19-13.042), p = 0.025] and duration on ART [≥5 years AOR 11.43(4.62-28.29), p = 0.001] were found as risk factors of subclinical atherosclerosis.

Conclusion

Subclinical atherosclerosis was higher in ART-experienced patients, and this was irrespective of presence or absence of traditional risk factors. And advancing HIV disease and duration on ART were found as significant risk factors for subclinical atherosclerosis. We therefore recommend routine CVD risk screening in PLHIV.

Vascular dysfunction and body mass index in African adults with HIV

BACKGROUND

Impaired vascular compliance is common among persons with HIV (PWH) and a risk factor for cardiovascular disease (CVD), though many studies documenting this are from regions with a high prevalence of overweight and obesity. The prevalence and characteristics of impaired vascular compliance among PWH with low body mass index (BMI) is not well described, particularly in sub-Saharan Africa (SSA) where the majority of PWH live, a low BMI is more common, and the burden of CVD is rising.

AIM

To assess non-invasive vascular compliance measurements, including augmentation index (AIX), pulse wave velocity (PWV) and pulse waveforms, in underweight, normal weight, and overweight PWH on long-term antiretroviral therapy (ART) in SSA.

METHODS

A cross-sectional study among PWH on ART at the University Teaching Hospital in Lusaka, Zambia. All participants had been on a regimen of efavirenz, emtricitabine, and tenofovir disoproxil fumarate for five or more years. Carotid-femoral PWV (cfPWV), carotid-radial PWV (crPWV), and the corresponding augmentation indexes (cfAIX and crAIX), were measured in all participants, in addition to aortic pressure waveforms, classified as type A, B, C and D according to reflected wave timings and amplitude. Multiple linear regression assessed relationships between demographic and clinical factors with vascular measurement endpoints.

RESULTS

Ninety one PWH on long-term ART were enrolled; 38 (42%) were underweight (BMI < 18.5 kg/m²), 43 (47%) were normal weight (18.5-24.9 kg/m²) and 10 (11%) were overweight (> 25 kg/m²). Median age was 41, 40 and 40 years, among the three groups, respectively, and the proportion of women increased with BMI level. Overweight participants had a 39% higher cfAIX compared to normal-weight participants, while being underweight was associated with 27% lower cfAIX, after adjusting for age, sex and blood pressure (P = 0.02 and P = 0.01, respectively), but measurements of cfPWV, crPWV and crAIX did not differ.

CONCLUSION

Underweight PWH in SSA had lower cfAIX measurements compared to normal weight individuals, indicating less arterial stiffness. However, similar cfPWV, crPWV and crAIX values among the underweight and overweight PWH suggest a low BMI may not confer substantial protection against impaired vascular compliance as a contributor to CVD risk among individuals on ART.

Association of HIV, cardiovascular risk factors, and carotid intimal media thickness: A cross-sectional study in Western Kenya

The carotid intimal media thickness (CIMT) is a validated measure of subclinical atherosclerosis. Human immunodeficiency virus (HIV) is a risk factor for cardiovascular disease (CVD) and has been associated with CIMT in North America and Europe; however, there are limited data from Sub-Saharan Africa (SSA). In this cross-sectional study, we measured CIMT in a cohort of 262 people living with HIV (PLHIV) on antiretroviral therapy (ART) for ≥6 months and HIV-negative adults in western Kenya. Using linear regression, we examined the associations between CVD risk factors and CIMT, both overall and stratified according to the HIV status. Among the PLHIV, we examined the association between CIMT and HIV-related factors. Of 262 participants, approximately half were women. The HIV-negative group had a higher prevalence of age ≥55 years (P = .002), previously diagnosed hypertension (P = .02), treatment for hypertension (P = .03), and elevated blood pressure (BP) (P = .01). Overall prevalence of carotid plaques was low (15/262 [6.0%]). HIV-positive status was not significantly associated with a greater mean CIMT (P = .19). In multivariable regression models, PLHIV with elevated blood pressure or treatment for hypertension had a greater mean CIMT (P = .002). However, the CD4 count, viral load, and ART regimen were not associated with differences in CIMT. In the HIV-negative group, older age (P = .006), high total cholesterol levels (P = .01), and diabetes (P = .02) were associated with a greater mean CIMT. In this cross-sectional study of Kenyan adults, traditional CVD risk factors were found to be more prevalent among HIV-negative participants. After multivariable regression analysis, we found no association between HIV status and CIMT, and PLHIV had fewer CVD risk factors associated with CIMT than HIV-negative participants did. HIV-specific factors were not associated with the CIMT.

Association of HIV Infection With Cardiovascular Pathology Based on Advanced Cardiovascular Imaging: A Systematic Review

IMPORTANCE

HIV-associated cardiovascular disease is increasing in prevalence, but its mechanisms remain poorly understood.

OBJECTIVE

To systematically review data from advanced cardiovascular imaging studies evaluating computed tomographic coronary angiography, positron emission tomography (PET), and cardiac magnetic resonance (MR), in people living with HIV compared with uninfected individuals.

DATA SOURCES

Three databases and Google Scholar were searched for studies assessing cardiovascular pathology using computed tomographic coronary angiography, cardiac MR, PET, and HIV from inception to February 11, 2022.

STUDY SELECTION

Two reviewers selected original studies without any restrictions on design, date, or language, investigating HIV and cardiovascular pathology.

DATA EXTRACTION AND SYNTHESIS

One investigator extracted data checked by a second investigator. Prevalence ratios (PRs) and differences in inflammation among people living with HIV and uninfected individuals were qualitatively synthesized in terms of cardiovascular pathology. Study quality was assessed using the National Heart, Lung, and Blood Institute quality assessment tool for observational studies.

MAIN OUTCOMES AND MEASURES

Primary outcomes were computed tomographic coronary angiography-defined moderate to severe (≥50%) coronary stenosis, cardiac MR-defined myocardial fibrosis identified by late gadolinium enhancement, and PET-defined vascular and myocardial target to background ratio. Prevalence of moderate to severe coronary disease, as well as myocardial fibrosis, and PRs compared with uninfected individuals were reported alongside difference in vascular target to background ratio.

RESULTS

Forty-five studies including 5218 people living with HIV (mean age, 48.5 years) and 2414 uninfected individuals (mean age, 49.1 years) were identified. Sixteen studies (n = 5107 participants) evaluated computed tomographic coronary angiography; 16 (n = 1698), cardiac MRs; 10 (n = 681), vascular PET scans; and 3 (n = 146), both computed tomographic coronary angiography and vascular PET scans. No studies originated from low-income countries. Regarding risk of bias, 22% were classified as low; 47% moderate; and 31% high. Prevalence of moderate to severe coronary disease among those with vs without HIV ranged from 0% to 52% and 0% to 27%, respectively, with PRs ranging from 0.33 (95% CI, 0.01-15.90) to 5.19 (95% CI, 1.26-21.42). Prevalence of myocardial fibrosis among those with vs without HIV ranged from 5% to 84% and 0% to 68%, respectively, with PRs ranging from 1.01 (95% CI, 0.85-1.21) to 17.35 (95% CI, 1.10-274.28). Differences in vascular target to background ratio among those with vs without HIV ranged from 0.06 (95% CI, 0.01-0.11) to 0.37 (95% CI, 0.02-0.72).

CONCLUSIONS AND RELEVANCE

In this systematic review of studies of advanced cardiovascular imaging, the estimates of the associations between HIV and cardiovascular pathologies demonstrated large amounts of heterogeneity. The findings provide a summary of the available data but may not be representative of all individuals living with HIV, including those from low-income countries with higher HIV endemicity.

Association between HIV and Prevalent Hypertension and Diabetes Mellitus in South Africa: Analysis of a Nationally Representative Cross-Sectional Survey

OBJECTIVES

Cardiovascular disease (CVD) burden is increasing among persons living with HIV (PLWH) in sub-Saharan Africa. It is unclear whether this reflects absolute increase in HIV-related CVD risk or unmasking by improved survival. Therefore, we examined whether HIV is associated with adverse cardiometabolic profiles among South African adults.

METHODS

We analyzed a nationally representative dataset (n=6420), estimating the weighted prevalence of hypertension, diabetes, and 10-year predicted risk of incident fatal/nonfatal CVD (if aged ≥40 years). Associations between HIV and cardiometabolic indices were assessed using log-binomial regression models adjusted for sociodemographic factors.

RESULTS

HIV population prevalence was 18.9%, with a median age of 36 years. Hypertension (44.2% vs 45.4%), diabetes (18.6% vs 20.4%), and overweight/obesity (body mass index ≥25 kg/m²: 54.9% vs 52.0%) prevalence did not substantially differ by HIV status, although PLWH had a lower 10-year predicted CVD risk (median: 5.1% vs 13.5%). In adjusted models, females who are HIV-negative had a 5 mm Hg higher median systolic blood pressure (128 vs 123 mmHg) than female PLWH.

CONCLUSIONS

PLWH in South Africa have better cardiometabolic disease profiles than the general population, and social determinants, rather than HIV, may have a greater influence on cardiometabolic risk. Designating PLWH a CVD high-risk group in South Africa is likely unwarranted.

Macular Changes Observed on Optical Coherence Tomography Angiography in Patients Infected With Human Immunodeficiency Virus Without Infectious Retinopathy

Purpose

As the human immunodeficiency virus (HIV) pandemic is far from over, whether there are subclinical macular changes in HIV-positive patients is something that should not be overlooked. We aimed to apply optical coherence tomography angiography (OCTA) to assess the macular structure and microvasculature changes in patients with HIV without infectious retinopathy.

Methods

HIV-positive and -negative participants were included and classified into three groups: HIV-negative, HIV-positive, and HIV-positive with microvasculopathy. OCTA parameters regarding macular structure and microvasculature were analyzed.

Results

Compared with the HIV-negative group, the superficial retinal vessel density (VD) in the parafovea sectors and the whole Early Treatment of Diabetic Retinopathy Study (ETDRS) grid and the choroidal vascularity index (CVI) in the whole ETDRS grid were significantly decreased in the HIV-positive and HIV-positive with microvasculopathy groups (p < 0.05). No differences were found in OCTA parameters between the HIV-positive and HIV-positive with microvasculopathy groups. Retinal, retinal nerve fiber layer-ganglion cell layer-inner plexiform layer (RNFL-GCL-IPL), RNFL, GCL-IPL, and INL thickness showed a negative association with the duration of HIV diagnosis or antiretroviral therapy (ART) (all p < 0.05). All OCTA microvasculature parameters showed no association with HIV-related clinical variables (all p > 0.05).

Conclusions

Subclinical macular changes existed in HIV-infected patients without clinical infectious retinopathy. Substructures from inner retinal layers might be associated with HIV infection or ART duration.

Age-related differences in the vascular function and structure of South Africans living with HIV

Background

As the life expectancy of people living with the HIV increases because of antiretroviral treatment (ART), their risk for vascular co-morbidities and early vascular ageing (EVA) also increases.

Objective

We aimed to investigate whether HIV infection relates to vascular structure and function in black South African adults and whether this relationship is age dependent.

Method

This cross-sectional study carried out in urban and rural areas of North West province, South Africa, included 572 age- and sex-matched people living with HIV (PLWH) and without HIV. Participants from the EndoAfrica study and PURE study were stratified according to tertiles of age. Measures of vascular structure (carotid intima-media thickness) and function (carotid-femoral pulse wave velocity, central systolic blood pressure, central pulse pressure and pulse pressure amplification) were determined.

Results

Blood pressure measures were lower in PLWH compared with their controls (all P ≤ 0.001), especially in the younger and middle-aged groups (all P ≤ 0.031), whilst vascular measures did not differ (all P ≥ 0.611). In multivariate linear regression analyses, vascular measures were not associated with a HIV- positive status in either the total or any of the age groups.

Conclusion

Black South Africans living with HIV have a less adverse blood pressure profile than their counterparts without HIV. The HIV-positive status was not associated with measures of vascular structure or function in any age group. The results suggest that HIV does not contribute to EVA in this population; however, further longitudinal investigation is warranted.

The influence of smoking and HIV infection on pulmonary function

Background

Prevalence of HIV, smoking, and pulmonary infections in South Africa are high.

Objectives

We investigated the role of smoking and HIV status on lung function.

Methods

This is a secondary analysis of a cross-sectional study conducted in South Africa. Data included demographics, pulmonary risk factors and a spirometry test to obtain the forced expiratory volume in one second (FEV1) and the ratio of FEV1/forced vital capacity (FVC). In the initial multivariable regression analysis, the effect of smoking on pulmonary function in HIV-positive adults was assessed. The analysis was repeated, assessing the influence of HIV status on lung function in both HIV-negative and HIV-positive smokers. The models were adjusted for age, sex, body mass index (BMI), time since HIV diagnosis, antiretroviral treatment (ART) use, occupational hazards, history of tuberculosis or pneumonia, indoor smoking and the presence of an indoor fireplace during childhood.

Results

This study included 524 people living with HIV (PLWH, 66.7% female, mean age 40.9 years [s.d.; 9.4]) and 79 HIV-negative smokers (77.2% male, mean age 34.4 years [s.d.: 12.1]). Of the PLWH, 118 (22.5%) were past or current smokers and 406 (77.5%) were non-smokers. Smoking was not associated with changes in the FEV1 or FEV1/FVC ratio in multivariable regression analysis. In the second analysis, HIV status was also not associated with reduced pulmonary function following adjustment for confounders.

Conclusion

Neither smoking nor being HIV-positive was associated with decreased pulmonary function in this relatively young population. These findings should be confirmed in a longitudinal study, including an older population.

Ischemic Heart Disease in Nigeria: Exploring the Challenges, Current Status, and Impact of Lifestyle Interventions on Its Primary Healthcare System

The burden of ischemic heart disease in Nigeria calls for an evidence-based, innovative, and interdisciplinary approach towards decreasing health inequalities resulting from individual lifestyle and poor socioeconomic status in order to uphold the holistic health of individuals to achieve global sustainability and health equity. The poor diagnosis and management of ischemic heart disease in Nigeria contributes to the inadequate knowledge of its prognosis among individuals, which often results in a decreased ability to seek help and self-care. Hence, current policies aimed at altering lifestyle behaviour to minimize exposure to cardiovascular risk factors may be less suitable for Nigeria's diverse culture. Mitigating the burden of ischemic heart disease through the equitable access to health services and respect for the autonomy and beliefs of individuals in view of achieving Universal Health Coverage (UHC) requires comprehensive measures to accommodate, as much as possible, every individual, notwithstanding their values and socioeconomic status.

Prevalence and correlates of carotid plaque in a mixed HIV-serostatus cohort in Uganda

BACKGROUND

The extent to which the risk of atherosclerotic cardiovascular disease (ACVD) is increased among people living with HIV (PLWH) in sub-Saharan Africa remains unknown.

SETTING

Cross-sectional analysis nested within the Ugandan Noncommunicable Diseases and Aging Cohort, including PLWH in rural Uganda > 40 years taking antiretroviral therapy (ART) for at least 3 years, and a population-based control group of HIV-uninfected age- and sex-matched persons.

METHODS

We conducted carotid ultrasonography and collected ACVD risk factor data. Our outcome of interest was carotid plaque, defined as > 1.5 mm thickness from the intima-lumen interface to the media-adventitia interface. We fit multivariable logistic regression models to estimate correlates of carotid plaque including HIV-specific and traditional cardiovascular risk factors.

RESULTS

We enrolled 155 (50.2%) PLWH and 154 (49.8%) HIV-uninfected comparators, with a mean age of  51.4 years. Among PLWH, the median CD4 count was 433 cells/mm³ and 97.4% were virologically suppressed. Carotid plaque prevalence was higher among PLWH (8.4% vs 3.3%). HIV infection (aOR 3.90; 95% CI 1.12-13.60) and current smokers (aOR 6.60; 95% CI 1.22-35.80) had higher odds of carotid plaque, whereas moderate (aOR 0.13, 95% CI 0.01-1.55) and vigorous intensity of physical activity (aOR 0.34, 95% CI 0.07-1.52) were associated with decreased odds of carotid plaque.

CONCLUSION

In rural Uganda, PLWH have higher prevalence of carotid plaque compared to age- and sex-matched HIV-uninfected comparators. Future work should explore how biomedical and lifestyle modifications might reduce atherosclerotic burden among PLWH in the region.

Treated HIV Infection and Progression of Carotid Atherosclerosis in Rural Uganda: A Prospective Observational Cohort Study

Background Although ≈70% of the world's population of people living with HIV reside in sub-Saharan Africa, there are minimal prospective data on the contributions of HIV infection to atherosclerosis in the region. Methods and Results We conducted a prospective observational cohort study of people living with HIV on antiretroviral therapy >40 years of age in rural Uganda, along with population-based comparators not infected with HIV. We collected data on cardiovascular disease risk factors and carotid ultrasound measurements annually. We fitted linear mixed effects models, adjusted for cardiovascular disease risk factors, to estimate the association between HIV serostatus and progression of carotid intima media thickness (cIMT). We enrolled 155 people living with HIV and 154 individuals not infected with HIV and collected cIMT images at 1045 visits during a median of 4 annual visits per participant (interquartile range 3-4, range 1-5). Age (median 50.9 years) and sex (49% female) were similar by HIV serostatus. At enrollment, there was no difference in mean cIMT by HIV serostatus (0.665 versus 0.680 mm, P=0.15). In multivariable models, increasing age, blood pressure, and non-high-density lipoprotein cholesterol were associated with greater cIMT (P<0.05), however change in cIMT per year was also no different by HIV serostatus (0.004 mm/year for HIV negative [95% CI, 0.001-0.007 mm], 0.006 mm/year for people living with HIV [95% CI, 0.003-0.008 mm], HIV×time interaction P=0.25). Conclusions In rural Uganda, treated HIV infection was not associated with faster cIMT progression. These results do not support classification of treated HIV infection as a risk factor for subclinical atherosclerosis progression in rural sub-Saharan Africa. Registration URL: https://www.ClinicalTrials.gov; Unique identifier: NCT02445079.

Relationship between sleep disorders, HIV status and cardiovascular risk: cross-sectional study of long-haul truck drivers from Southern Africa

OBJECTIVES

Long-haul truck drivers (TDs) may have lifestyles that promote cardiovascular disease (CVD), including diet, sleep and activity issues. Most studies conducted among truckers investigated the relationship between poor sleep and cardiometabolic health, but none assessed whether suspected obstructive sleep apnoea (OSA) and shortened sleep were associated with markers of cardiometabolic risk. We determined whether sleep disorders and circadian misalignment were associated with chronic inflammation and CVD risk in TDs from Southern Africa.

METHODS

Participants were recruited at roadside wellness centres in Gauteng and Free State Provinces, South Africa. OSA risk was assessed using the Berlin Questionnaire, while sleep duration and sleep quality were assessed using items from the Pittsburgh Sleep Quality Index. Clinical information, neck circumference (NC), metabolic profile, elevated BP, HIV status and C-reactive protein (CRP) were collected. CVD risk was assessed using the Framingham Risk Score (FRS).

RESULTS

Out of 575 participants aged on average 37.7 years, 17.2% were at OSA risk, 72.0% had elevated BP, 9.4% had HIV and 28.0% were obese. Mean sleep duration was 7.4±1.8 hours, and 49.6% reported working night shift at least once a week. Shortened sleep, OSA risk, age, body mass index, NC and years as full-time TD were associated with greater FRS independently of HIV status and night shift. Working night shift was associated with higher CRP levels in HIV+ compared with HIV- participants.

CONCLUSIONS

Circadian misalignment in HIV, and OSA and short sleep duration in all truckers were associated with increased CVD risk. Truckers should be given careful attention in terms of health management and sleep education.

Imaging modalities for cardiovascular phenotyping in asymptomatic people living with HIV

Cardiovascular disease (CVD) has emerged as a leading cause of non-HIV-related mortality among people living with HIV (PLWH). Despite the growing CVD burden in PLWH, there is concern that general population risk score models may underestimate CVD risk in these patients. Imaging modalities have received mounting attention lately to better understand the pathophysiology of subclinical CVD and provide improved risk assessment in this population. To date, traditional and well-established techniques such as echocardiography, pulse wave velocity, and carotid intima thickness continue to be the basis for the diagnosis and subsequent monitoring of vascular atherosclerosis and heart failure. Furthermore, novel imaging tools such as cardiac computed tomography (CT) and cardiac CT angiography (CCTA), positron emission tomography/CT (PET/CT), and cardiac magnetic resonance (CMR) have provided new insights into accelerated cardiovascular abnormalities in PLWH and are currently evaluated with regards to their potential to improve risk stratification.

HIV-related cardiovascular disease: any role for high-density lipoproteins?

The introduction of antiretroviral therapy (ART) has improved the life expectancy of patients infected with human immunodeficiency virus (HIV). However, this population is at an increased risk for noncommunicable diseases, including atherosclerotic cardiovascular disease (CVD). Both ART and viral infection may be potential contributors to the pathophysiology of HIV-related CVD. The mechanisms behind this remain unclear, but it is critical to delineate early biomarkers of cardiovascular risk in the HIV population. In this review, we postulate that potential biomarkers could include alterations to high-density lipoprotein (HDL). Indeed, recent data suggest that HIV and ART may induce structural changes of HDL, thus resulting in shifts in HDL subclass distribution and HDL functionality.

Increased prevalence of hypertension among people living with HIV: where to begin?

INTRODUCTION

Cardiovascular diseases (CDVs) have become increasingly important for progressively older people living with HIV (PLHIV). Identification of gaps requiring improvement in the care cascade for hypertension, a primary risk factor for CVDs, is of utmost importance. This study analyzed the prevalence of hypertensive status and described the care cascade for hypertension screening, diagnosis, treatment, treatment adherence, and management in PLHIV.

METHODS

This cross-sectional study included 298 PLHIV (age >40 years) who visited a referral center in the western Brazilian Amazon. Data were collected through a structured questionnaire interview and medical examinations. Thus, information regarding sociodemographic and clinical aspects, blood pressure, weight, height, body mass index, and laboratory profile was obtained. Descriptive and analytical statistics were performed, and results were considered significant ifp <0.05.

RESULTS

In total, 132 (44.3%) participants reported that their blood pressure was never measured. The prevalence of hypertension was found to be 35.9% (107/298). Of these 107 participants, only 36 (33.6%) had prior knowledge of their hypertensive status, and 19 of 36 (52.7%) participants had visited a physician or cardiologist to seek treatment. Adherence to the BP-lowering treatment was noted in 11 (10.2%) participants.

CONCLUSIONS

An increased prevalence of hypertension was found, and most of the hypertensive participants were unaware of their hypertensive status. In addition, blood pressure control was poor in the study population. This indicated that public health professionals did not sufficiently consider the full spectrum of healthcare and disease management for PLHIV.

Cardiovascular Disease Burden in Rural Africa: Does HIV and Antiretroviral Treatment Play a Role?: Baseline Analysis of the Ndlovu Cohort Study

Background

HIV is associated with an increased risk of cardiovascular disease (CVD) in high‐income countries. Little is known about the CVD burden in sub‐Saharan Africa, where 70% of the world's HIV‐positive population lives. This study aims to provide insight into the burden of CVD risk in a rural setting in sub‐Saharan Africa considering HIV infection and antiretroviral therapy (ART).

Methods and Results

A cross‐sectional analysis was conducted of the baseline of the Ndlovu Cohort study including HIV‐negative and HIV‐positive participants in rural South Africa between 2014 and 2017. Information was collected on demographics, socioeconomic status, and CVD risk factors. Carotid intima‐media thickness measurement was performed. The influence of HIV and ART on the burden of CVD was determined by comparing HIV‐positive participants who were ART naive on first‐line or second‐line ART with HIV‐negative participants. In total, 1927 participants were included, of whom 887 (46%) were HIV positive and 54% women. The median age was 38 years. Overall, 690 participants (79%) were on ART, with 613 (89%) on first‐line and 77 (11%) on second‐line therapy. Participants with HIV had lower values for most of the CVD risk factors but higher C‐reactive protein levels than HIV‐negative participants. ART‐naive, HIV‐positive participants had similar carotid intima‐media thickness compared with HIV‐negative participants but carotid intima‐media thickness was increased for participants on ART aged 30 years and older compared with HIV‐negative participants.

Conclusions

HIV‐positive participants presented with a favorable CVD risk profile compared with HIV‐negative participants. However, carotid intima‐media thickness was increased in HIV‐positive participants on ART, indicating a higher burden of subclinical CVD for the HIV‐positive population.