Prevalence and Characteristics of HIV-Associated Stroke in a Tertiary Hospital Setting in South Africa

The role of atherosclerosis in HIV-associated vasculopathy in young South African stroke patients

BACKGROUND

HIV-associated vasculopathy is known to cause stroke in people living with HIV (PLWH). The role of atherosclerosis is unclear. We assessed the aetiology of vasculopathy in PLWH and tested the utility of markers of subclinical atherosclerosis to distinguish atherosclerotic (AV) from non-atherosclerotic vasculopathy (NAV).

METHODS

This cross-sectional study recruited PLWH with stroke at a hospital in Johannesburg, South Africa, from 2014 to 2017. Patients with meningitis were excluded. Cerebrospinal fluid (CSF) was tested for multi-viral polymerase chain reaction, including varicella zoster virus (VZV). Once an aetiological category was assigned, carotid intima-media thickness (cIMT) and aortic pulse wave velocity (PWV) were compared in AV and NAV, and to predetermined thresholds for subclinical atherosclerosis (cIMT≥0.70 mm, PWV≥10.00 m/s).

RESULTS

Some 28/85 PLWH (32.9%) vs. 9/109 (8.3%, p < 0.0001) people-without-HIV had vasculopathy on computed tomography angiography. Only four PLWH had AV. Compared with NAV (n = 11), those with AV were older (50.0 ± 4.1 vs. 39.2 ± 9.2 years, p = 0.04) and had more cardiovascular risk factors (median 2.0 [IQR 1.5-2.5] vs. 0.0 [IQR 0.0-1.0], p = 0.02). cIMT in AV was higher than in NAV (1.01 ± 0.07 mm [n = 4] vs. 0.63 ± 0.04 mm [n = 9], p < 0.001). All with AV had cIMT and PWV above the predetermined thresholds, while all except one with NAV were below. We found evidence of VZV in eight PLWH and HIV-associated vasculitis in six.

CONCLUSIONS

Vasculopathy in PLWH in our region appears to be predominantly non-atherosclerotic. cIMT and PWV were useful adjuncts in distinguishing AV from NAV. Despite excluding meningitis, VZV was implicated in a large proportion, emphasizing the likely underdiagnosis of this treatable infection. We thus recommend CSF VZV testing in all PLWH with stroke.

Stroke, HIV and the Immune Reconstitution Inflammatory Syndrome in the absence of opportunistic infections

INTRODUCTION

Stroke in people living with HIV (PLWH) has been described to occur soon after the initiation of antiretroviral therapy (ART) possibly related to the Immune Reconstitution Inflammatory Syndrome (IRIS). We sought to investigate whether there was a temporal association between stroke and recent ART initiation in the absence of opportunistic infections (OIs), and to identify risk factors for this.

METHODS

This cross-sectional study recruited PLWH with new-onset stroke at a hospital in Johannesburg, South Africa, from 2014 to 2017, excluding all patients with OIs. Patients were assessed for ART duration, CD4 count, HIV viral load, inflammatory markers and cardiovascular risk factors.

RESULTS

77 PLWH were recruited, of which 35 were on ART at the time of stroke. Of the patients with confirmed ART duration (n = 28), 9 (32.1%) had a stroke within the first 6 months of starting ART (crude incidence rate of 0.73 cases per patient year). In the period beyond 6 months, 19 strokes occurred (crude incidence rate of 0.21 cases per patient year), translating to a 3.5 times greater risk in the first 6 months (p = 0.0002). There were no clearly identified risk factors when comparing those who had strokes in the first 6 months to those after 6 months and ART-naïve patients.

CONCLUSION

Almost a third of strokes in PLWH may be related to IRIS, with a crude incidence rate 3.5 times higher in the first 6 months following ART-initiation compared to beyond 6 months. This appears to be independent of OIs. Risk factors are unclear.