Current Efavirenz (EFV) or ritonavir-boosted lopinavir (LPV/r) use correlates with elevate markers of atherosclerosis in HIV-infected subjects in Addis Ababa, Ethiopia

Serum Lipid Profiles, Blood Glucose, and High-Sensitivity C-Reactive Protein Levels Among People Living with HIV Taking Dolutegravir and Ritonavir-Boosted Atazanavir-Based Antiretroviral Therapy at Jimma University Medical Center, Southwest Ethiopia, 2021

Background

Long-term use of antiretroviral therapy, especially dolutegravir and boosted-atazanavir, raises concerns about cardiovascular disease. Thus, this study aimed to assess lipid profiles, blood glucose, and high-sensitivity C-reactive protein levels among people living with HIV on dolutegravir and ritonavir-boosted atazanavir-based therapy.

Methods

An institutional-based comparative cross-sectional study was conducted from November 4, 2021, to January 4, 2022. An equal number of dolutegravir- and ritonavir-boosted atazanavir-treated patients (n = 64 each) was enrolled. A consecutive sampling was used to select participants. The Chi-square, Student's t-test, Mann-Whitney U-test, and logistic regression were used as appropriate statistical tests using SPSS Version 25.0. Statistical significance was set at p < 0.05.

Results

Dyslipidemia was found in 67.2% (43/64) of ritonavir-boosted atazanavir group and 48.4% (31/64) of dolutegravir group. The dolutegravir group had significantly higher mean and median values of high-density lipoprotein and random blood sugar, respectively, as well as lower median triglyceride and high-sensitivity C-reactive protein levels than the ritonavir-boosted atazanavir group. Ritonavir-boosted atazanavir-based regimens (AOR=3.4, 95% CI: 1.5, 8) and age >40 years were predictors of dyslipidemia, while BMI ≥25 kg/m2 (AOR=3.7, 95% CI: 1.3, 10.8) and dolutegravir-based regimens (AOR=4.6, 95% CI: 1.5, 14) were predictors of hyperglycemia. Ritonavir-boosted atazanavir-based regimens (ARR=3, 95% CI: 1.3, 8) and BMI ≥25 kg/m2 (ARR=2.5, 95% CI: 1.1, 6) were associated with increased high-sensitivity C-reactive protein by 1-3 mg/L. The risk of increased high-sensitivity C-reactive protein by >3 mg/L was greater in those patients with a CD4 cell count of <500 cells/mm3 (ARR=5, 95% CI: 1.1, 24).

Conclusion

When compared to ritonavir-boosted atazanavir-based regimens, dolutegravir had favorable lipid profiles and high-sensitivity C-reactive protein but unfavorable blood glucose levels. Therefore, baseline blood glucose, lipid profiles, and high-sensitivity C-reactive protein levels should be routinely measured in patients on these regimens.

High-sensitivity C-reactive protein among people living with HIV on highly active antiretroviral therapy: a systemic review and meta-analysis

The pathological consequences of inflammation persist in people living with the human immunodeficiency virus (PLWH), regardless of the positive outcomes of highly active antiretroviral therapy (HAART). The current systematic review and meta-analysis aims to understand and explore the levels of high-sensitivity C-reactive protein (hs-CRP) and other cardiovascular disease (CVD)-risk factors including lipid profiles among PLWH on HAART. Major electronic databases including PubMed, Scopus, and Web of Science were searched to retrieve relevant global literature reporting on hs-CRP levels in PLWH on HAART. A total of twenty-two studies with an average participant age of 40 years were eligible for this systematic review and meta-analysis. Majority of the included studies were from Africa (n = 11), the United States (n = 6), and Europe (n = 5). Our systemic review showed that most studies reported increased levels of hs-CRP among PLWH on HAART when compared to controls (PLWH not on HAART or those without HIV), especially in studies from Africa. This was supported by a meta-analysis showing significantly elevated levels of hs-CRP in PLWH on HAART when compared to PLWH not on HAART (standardised mean difference [SMD] = 0.56; 95% CI = 0.10‑1.01, z = 2.41; p = 0.02) or those without HIV (SMD = 1.19; 95% CI = 0.76‑1.63, z = 5.35; p < 0.001). Where lipid profiles, as a major predictor for CVD risk, were also impaired in PLWH on HAART when compared to PLWH not on HAART and HIV-negative participants. In conclusion, elevated levels of hs-CRP and lipid levels are prevalent in PLWH on HAART, this may increase the risk of CVD complications, especially for those people living in Africa. However, more evidence in larger population studies is required to confirm these outcomes and unveil any possible clinical implications of HAART-induced modulation of hs-CRP levels in PLWH.

Prevalence and risk factors of metabolic syndrome in Ethiopia: describing an emerging outbreak in HIV clinics of the sub-Saharan Africa - a cross-sectional study

OBJECTIVES

HIV-induced chronic inflammation, immune activation and combination antiretroviral therapy (cART) are linked with adverse metabolic changes known to cause cardiovascular adversities. This study evaluates the prevalence of lipodystrophy, and metabolic syndrome (MetS), and analyses risk factors in HIV-infected Ethiopians taking cART.

METHODS

A multicentre cross-sectional study was conducted at tertiary-level hospitals. Eligible participants attending the HIV clinics were enrolled. Sociodemographic, anthropometric, clinical, HIV treatment variables, lipid profile, fasting blood glucose level, risk factors and components of MetS, also lipodystrophy, were studied. Data were analysed by SPSS statistical package V.25 with descriptive and analytical statistics. For multivariable analysis of risk factors, a logistic regression model was used. Results were presented in frequency and percentages, mean±SD, or median+IQR. Statistical significance was taken as p<0.05.

RESULTS

Among 518 studied participants, two-thirds were females, and the mean age of the study population was 45 years (SD=11). The mean duration of cART was 10 years (SD=4). Median CD4 count was 460 cells/mm3. The prevalence of MetS according to the Adult Treatment Panel III (2005) criteria was 37.6%. In multivariable analysis, independent risk factors for MetS were age >45 years (aHR 1.8, 95% CI 1.2 to 2.4), female sex (aHR 1.8, 95% CI 1.1 to 2.8), body mass index (BMI)>25 kg/m2 (aHR 2.7, 95% CI 1.8 to 4.1), efavirenz-based cART (aHR 2.8, 95% CI 1.6 to 4.8) and lopinavir/ritonavir-based cART (aHR 3.7, 95% CI 1.0 to 13.3). The prevalence of lipodystrophy was 23.6%. Prior exposure to a stavudine-containing regimen was independently associated with lipodystrophy (aHR 3.1, 95% CI 1.6 to 6.1).

CONCLUSION

Our study revealed 38% of the participants had MetS indicating considerable cardiovascular disease (CVD) risks. Independent risk factors for MetS were BMI≥25 kg/m2, efavirenz and lopinavir/ritonavir-based cART, female sex and age ≥45 years. In addition to prevention, CVD risk stratification and management will reduce morbidity and mortality in people with HIV infection.

Association between cardio-ankle vascular index and cardiometabolic risk factors in HIV patients in Ghana

Human immunodeficiency virus (HIV) infection is associated with increased cardiovascular diseases (CVDs) even in patients with viral suppression by combination antiretroviral therapy (cART). Arterial stiffness is an independent predictor of CVDs in diseased individuals and the general population. Cardio-ankle vascular index (CAVI) is an index of arterial stiffness that has been shown to predict target organ damage. CAVI is less studied in HIV patients. We compared the levels of arterial stiffness using CAVI and associated factors among cART-treated and cART-naïve HIV patients to those of non-HIV controls. In a case-control design, 158 cART-treated HIV patients, 150 cART-naïve HIV patients and 156 non-HIV controls were recruited from a periurban hospital. We collected data on CVD risk factors, anthropometric characteristics, CAVI, and fasting blood samples to measure plasma glucose, lipid profile, and CD4+ cell counts. Metabolic abnormalities were defined using the JIS criteria. CAVI increased in cART-treated HIV patients compared to cART-naïve HIV patients and non-HIV controls (7.8 ± 1.4 vs 6.6 ± 1.1 vs 6.7 ± 1.4 respectively, p < 0.001). CAVI was associated with metabolic syndrome in non-HIV controls [OR (95% CI) = 2.14 (1.04-4.4), p = 0.039] and cART-naïve HIV patients [1.47 (1.21-2.38), p = 0.015], but not in cART-treated HIV patients [0.81 (0.52-1.26), p = 0.353]. In cART-treated HIV patients, a tenofovir (TDF)-based regimen (β = -0.46, p = 0.023) was associated with decreased CAVI and decreased CD4+ cell count (β = -0.23, p = 0.047) was associated with increased CAVI. In a periurban hospital in Ghana, compared to non-HIV controls or cART-naïve HIV patients, cART-treated HIV patients had increased arterial stiffness measured as CAVI. CAVI is associated with metabolic abnormalities in non-HIV controls and cART-naïve HIV patients, but not in cART-treated HIV patients. Patients on TDF-based regimens had decreased CAVI.

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.

Aortic Pressure Levels and Waveform Indexes in People Living With Human Immunodeficiency Virus: Impact of Calibration Method on the Differences With Respect to Non-HIV Subjects and Optimal Values

Background: There are scarce and controversial data on whether human immunodeficiency virus (HIV) infection is associated with changes in aortic pressure (aoBP) and waveform-derived indexes. Moreover, it remains unknown whether potential differences in aoBP and waveform indexes between people living with HIV (PLWHIV) and subjects without HIV (HIV-) would be affected by the calibration method of the pressure waveform.

Aims: To determine: (i) whether PLWHIV present differences in aoBP and waveform-derived indexes compared to HIV- subjects; (ii) the relative impact of both HIV infection and cardiovascular risk factors (CRFs) on aoBP and waveform-derived indexes; (iii) whether the results of the first and second aims are affected by the calibration method.

Methods: Three groups were included: (i) PLWHIV (n = 86), (ii) HIV- subjects (general population; n = 1,000) and (iii) a Reference Group (healthy, non-exposed to CRFs; n = 398). Haemodynamic parameters, brachial pressure (baBP; systolic: baSBP; diastolic: baDBP; mean oscillometric: baMBPosc) and aoBP and waveform-derived indexes were obtained. Brachial mean calculated (baMBPcalc=baDBP+[baSBP-baDBP]/3) pressure was quantified. Three waveform calibration schemes were used: systolic-diastolic, calculated (baMBPcalc/baDBP) and oscillometric mean (baMBPosc/baDBP).

Results: Regardless of CRFs and baBP, PLWHIV presented a tendency of having lower aoBP and waveform-derived indexes which clearly reached statistical significance when using the baMBPosc/baDBP or baMBPcalc/baDBP calibration. HIV status exceeded the relative weight of other CRFs as explanatory variables, being the main explanatory variable for variations in central hemodynamics when using the baMBPosc/baDBP, followed by the baMBPcalc/baDBP calibration.

Conclusions: The peripheral waveform calibration approach is an important determinant to reveal differences in central hemodynamics in PLWHIV.

Association of HIV Infection and Antiretroviral Therapy With Arterial Stiffness: A Systematic Review and Meta-Analysis

[Figure: see text].

HIV Protease Inhibitor Ritonavir Impairs Endothelial Function Via Reduction in Adipose Mass and Endothelial Leptin Receptor-Dependent Increases in NADPH Oxidase 1 (Nox1), C-C Chemokine Receptor Type 5 (CCR5), and Inflammation

Background Cardiovascular disease is currently the leading cause of death in patients with human immunodeficiency virus on combination antiretroviral therapy. Although the use of the protease inhibitor ritonavir has been associated with increased prevalence of cardiovascular disease, the underlying mechanisms remain ill-defined. Herein, we tested the hypothesis that ritonavir-mediated lipoatrophy causes endothelial dysfunction via reducing endothelial leptin signaling. Methods and Results Long-term (4 weeks) but not short-term (3 days) treatment with ritonavir reduced body weight, fat mass, and leptin levels and induced endothelial dysfunction in mice. Moreover, ritonavir increased vascular NADPH oxidase 1, aortic H₂O₂ levels as well as interleukin-1β, GATA3 (GATA binding protein 3), the macrophage marker (F4/80), and C-C chemokine receptor type 5 (CCR5) expression. Reactive oxygen species scavenging with tempol restored endothelial function, and both NADPH oxidase 1 and CCR5 deletion in mice protected from ritonavir-mediated endothelial dysfunction and vascular inflammation. Remarkably, leptin infusion markedly improved endothelial function and significantly reduced vascular NADPH oxidase 1, interleukin-1β, GATA3, F4/80, and CCR5 levels in ritonavir-treated animals. Selective deficiency in endothelial leptin receptor abolished the protective effects of leptin infusion on endothelial function. Conversely, selective increases in endothelial leptin signaling with protein tyrosine phosphatase deletion blunted ritonavir-induced endothelial dysfunction. Conclusions All together, these data indicate that ritonavir-associated endothelial dysfunction is a direct consequence of a reduction in adiposity and leptin secretion, which decreases endothelial leptin signaling and leads to a NADPH oxidase 1-induced, CCR5-mediated reduction in NO bioavailability. These latter data also introduce leptin deficiency as an additional contributor to cardiovascular disease and leptin as a negative regulator of CCR5 expression, which may provide beneficial avenues for limiting human immunodeficiency virus infection.

Aortic stiffness and central hemodynamics in treatment-naïve HIV infection: a cross-sectional study

Background

Human immunodeficiency virus (HIV) infection is associated with a greater risk of cardiovascular disease (CVD). HIV infection causes a chronic inflammatory state and increases oxidative stress which can cause endothelial dysfunction and arterial stiffness. Aortic stiffness measured by carotid femoral-pulse wave velocity (cfPWV) and central hemodynamics are independent cardiovascular risk factors and have the prognostic ability for CVD. We assessed cfPWV and central hemodynamics in young individuals with recent HIV infection diagnosis and without antiretroviral therapy. We hypothesized that individuals living with HIV would present greater cfPWV and central hemodynamics (central systolic blood pressure and pulse pressure) compared to uninfected controls.

Methods

We recruited 51 treatment-naïve individuals living with HIV (HIV(+)) without previous CVD and 51 age- and sex-matched controls (HIV negative (−)). We evaluated traditional CVD risk factors including metabolic profile, blood pressure (BP), smoking, HIV viral load, and CD4⁺ T-cells count. Arterial stiffness and central hemodynamics were evaluated by cfPWV, central systolic BP, and central pulse pressure (cPP) via applanation tonometry.

Results

HIV(+) individuals presented a greater prevalence of smoking, reduced high-density lipoprotein cholesterol, and body mass index. 65.9% of HIV(+) individuals exhibited lymphocyte CD4⁺ T-cells count < 500 cells/μL. There was no difference in brachial or central BP between groups; however, HIV(+) individuals showed significantly lower cPP. We observed a greater cfPWV (mean difference = 0.5 m/s; p < 0.01) in HIV(+) compared to controls, even after adjusting for heart rate, mean arterial pressure and smoking.

Conclusion

In the early stages of infection, non-treated HIV individuals present a greater prevalence of traditional CVD risk factors, arterial stiffness, and normal or in some cases central hemodynamics.

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.

Cardiovascular disease risk and its determinants in people living with HIV across different settings in South Africa

Objectives

Socio‐economic factors and lifestyle are known to differ across geographies and populations, which may result in distinct risk profiles for cardiovascular disease (CVD). This study assessed carotid intima‐media thickness (CIMT), a proxy for CVD, and its determinants in two groups of people living with HIV (PLHIV) in two different settings in South Africa.

Methods

A cross‐sectional analysis was conducted comparing data from the Ndlovu Cohort Study in the Limpopo Province (group 1) and from three clinical trials in Johannesburg (group 2). The association between demographics, conventional CVD risk factors, HIV‐related factors and CIMT in groups 1 and 2 was analysed with two separate multivariable linear regression models.

Results

Group 1 consisted of 826 participants (mean age 42.2 years) and mean (± standard deviation) CIMT was 0.626 ± 0.128 mm. In this group, sex, age, body mass index (BMI), cholesterol, glucose and antiretroviral therapy (ART) duration (β = 0.011 mm per 5 years; P = 0.02) were associated with higher CIMT. There were positive interactions between age and ART duration and age and cholesterol. Group 2 consisted of 382 participants (mean age 39.5 years) and mean (± standard deviation) CIMT was 0.560 ± 0.092 mm. In this group, only sex, education level, BMI and cholesterol were associated with higher CIMT, albeit with weaker associations than in group 1.

Conclusions

Conventional CVD risk factors were the main drivers of CIMT. The impact of some of these risk factors appeared to increase with age. Differences in sample size, age and viral suppression might explain why an effect of ART was observed in group 1 but not in group 2.

Cardiovascular disease risk in an urban African population: a cross-sectional analysis on the role of HIV and antiretroviral treatment

Background

Life expectancy is increasing in the HIV-positive population and age-related non-communicable diseases, such as cardiovascular disease, (CVD) are seen more frequently. This study investigated to what extent HIV and antiretroviral therapy (ART) is associated with CVD risk in an urban African population.

Methods

A cross-sectional study was performed in Johannesburg, South Africa, between July 2016 and November 2017. Both HIV-positive adults (ART-naïve, or on first- or second-line ART), as well as age and sex matched HIV-negative controls who were family or friends of the HIV-positive participants were included. Data were collected on demographics, cardiovascular risk factors, HIV-related characteristics, carotid intima-media thickness (CIMT) and carotid distensibility. The association between HIV, ART and CIMT and distensibility was analysed with linear regression models, adjusting for age, gender and CVD risk factors.

Results

The study included 548 participants, 337 (62%) females, age 38.3 ± 9.5 years of whom 104 (19.0%) were HIV-positive, ART-naïve; 94 (17.2%) were on first-line ART; 197 (35.9%) were on second-line ART; and 153 (27.9%) were HIV-negative. Participants on second-line ART had higher CIMT and lower distensibility compared to the other groups (p < 0.001). After adjustment for age, these outcomes were similar between groups. Further adjustment for CVD and HIV-related factors did not alter the findings.

Conclusion

Neither HIV nor ART was associated with CIMT or carotid distensibility in this urban African population. Longitudinal studies are needed to fully understand the relationship between HIV and CVD across different populations.

ICAM-1 in HIV infection and underlying mechanisms

Intercellular adhesion molecule 1 (ICAM-1) is a glycoprotein that participates in inflammatory and immune responses. Both cell surface and soluble ICAM-1 are significantly increased during human immunodeficiency virus (HIV) infection, and ICAM-1 has important functions in promoting inflammatory responses and enhancing HIV infectivity; however, a comprehensive summary these roles has yet to be elaborated. In this review we describe the general biological characteristics of ICAM-1, its association with HIV disease progression and promotion of HIV production, mechanisms inducing upregulation of ICAM-1, and possible intervention strategies, representing important insights in the context of HIV treatment.

Burden of subclinical carotid atherosclerosis and vascular risk factors among people living with HIV in Ghana

BACKGROUND

The burden of cardiovascular disease (CVD) among people living with HIV (PLWH) in sub-Saharan Africa is projected to rise due to a rapid epidemiological transition and improved treatment of HIV infection on the sub-continent.

OBJECTIVE

The Evaluation of Vascular Event Risk while on Long-term Anti-retroviral Suppressive Therapy (EVERLAST) Study sought to assess the extent of subclinical atherosclerosis and characterize the nature of CVD risk factors among HIV patients on Antiretroviral therapy (ART) in Ghana.

METHODS

We conducted a cross-sectional study involving HIV patients on antiretroviral therapy (n = 250) in comparison with HIV positive ART naïve (n = 201), and HIV uninfected controls (n = 250). We assessed prevalence of hypertension, dyslipidemia, diabetes mellitus, central obesity, and carotid atherosclerosis using B-mode carotid Doppler ultrasonography. We assessed factors associated with subclinical atherosclerosis defined by a carotid intimal media thickness (CIMT) cut-off of ≥0.78 mm among PLWH using a logistic regression model.

RESULTS

Mean age of PLWH on combination ART (cART) was 45.7 ± 8.6 years, 42.9 ± 8.8 years among PLWH not on cART, and 44.9 ± 9.5 years among HIV negative controls of which 81.2%, 81.6% and 81.1% respectively were females. Prevalence of subclinical atherosclerosis at the common carotid artery in the three groups was 67.6%, 66.7% and 62.4%, p = 0.43. Among PLWH, raised serum total cholesterol (OR 1.16, 95% CI: 1.00-1.35) and triglycerides (OR 1.32, 95% CI: 1.01-1.73) were significantly associated with subclinical atherosclerosis. Prevalence of vascular risk factors among PLWH on cART, PLWH cART naïve, and HIV negative controls respectively were as follows: dyslipidemia- 79.5%, 83.1%, and 73.5%, p = 0.04; hypertension- 40.2%, 23.4%, and 44.9%, p < 0.0001; central obesity-61.8%, 66.7%, and 78.2%, p < 0.0001; diabetes mellitus-6.8%, 5.5% and 4.9%, p = 0.53.

CONCLUSION

Overall while there is a high baseline prevalence of CVD risk factors in the Ghanaian population, serum lipid derangements appear to be more prevalent among HIV infected patients, and are linked to sub-clinical atherosclerosis. Future studies need to confirm these findings, explore the underlying pathophysiology, and optimize treatment strategies to avert untoward CVD outcomes.

Vascular endothelial dysfunction in the wake of HIV and ART

Mounting evidence points to increased rates of cardiovascular disease (CVD) among people living with HIV/AIDS (PLWHA). Endothelial dysfunction (loss of endothelium-dependent vascular relaxation in response to provasodilatory stimuli) constitutes an early pathophysiological event in atherogenesis and CVD. Both HIV-1 infection and antiretroviral therapy (ART) are implicated in the development of endothelial dysfunction; however, conclusions are frequently drawn from associations shown in epidemiological studies. In this narrative review of mainly in vitro and animal studies, we report on the current understanding of how various HIV-1 proteins, HIV-1-induced proinflammatory cytokines and common antiretroviral drugs directly impact vascular endothelial cells. Proposed cellular mechanisms underlying the switch to a dysfunctional state are discussed, including oxidative stress, impaired expression and regulation of endothelial nitric oxide (NO) synthase (eNOS) and increased expression of vascular adhesion molecules. From the literature, it appears that increased reactive oxygen species (ROS) production, linked to decreased NO bioavailability and ensuing endothelial dysfunction, may be proposed as a putative final common pathway afflicting the vascular endothelium in PLWHA. The HIV-1-proteins Tat, Gp120 and Nef in particular, the proinflammatory cytokine, TNF-α, and the antiretroviral drugs Efavirenz and Lopinavir, most commonly postulated to be primary causal agents of endothelial dysfunction, are also discussed. We conclude that, despite existing evidence from basic research papers, a significant gap remains in terms of the exact underlying cellular mechanisms involved in HIV-1 and ART induced endothelial dysfunction. Bridging this gap could help pave the way for future strategies to prevent and treat early cardiovascular changes in PLWHA.

Dyslipidemia among rural and urban HIV patients in south-east Malawi

Background

While dyslipidemia importantly contributes to increased cardiovascular disease risk among patients on antiretroviral therapy (ART), data on lipid patterns among African adults on ART are limited. We describe the prevalence of lipid abnormalities and associated factors in two HIV clinics in Malawi.

Methods

We conducted a cross-sectional study in 2014 and enrolled adult patients at a rural and an urban HIV clinic in Zomba district, Malawi. We recorded patient characteristics, CVD risk factors and anthropometric measurements, using the WHO STEPS validated instrument. Non-fasting samples were taken for determination of total cholesterol (TC), triglyceride (TG) and HDL-cholesterol (HDL-c) levels. Logistic regression analysis was used to determine factors associated with elevated TC and elevated TC/HDL-c ratio.

Results

554 patients were enrolled, 50% at the rural HIV clinic, 72.7% were female, the median (IQR) age was 42 years (36–50); 97.3% were on ART, 84.4% on tenofovir/lamivudine/efavirenz, 17.5% were overweight/obese and 27.8%% had elevated waist/hip ratio. 15.5% had elevated TC, 15.9% reduced HDL-c, 28.7% had elevated TG and 3.8% had elevated TC/HDL-c ratio. Lipid abnormalities were similar in rural and urban patients. Women had significantly higher burden of elevated TC and TG whereas men had higher prevalence of reduced HDL-c. Waist-to-hip ratio was independently associated with elevated TC (aOR = 1.90; 95% CI: 1.17–3.10, p = 0.01) and elevated TC/HDL-c ratio (aOR = 3.50; 95% CI: 1.38–8.85, p = 0.008). Increasing age was independently associated with elevated TC level (aOR = 1.54, 95% CI 0.51–4.59 for age 31–45; aOR = 3.69, 95% CI 1.24–10.95 for age >45 years vs. ≤30 years; p-trend <0.01).

Conclusions

We found a moderate burden of dyslipidemia among Malawian adults on ART, which was similar in rural and urban patients but differed significantly between men and women. High waist-hip ratio predicted elevated TC and elevated TC/HDL-c ratio and may be a practical tool for CVD risk indication in resource limited settings.

The association between HIV and atherosclerotic cardiovascular disease in sub-Saharan Africa: a systematic review

Background

Sub-Saharan Africa (SSA) has confronted decades of the HIV epidemic with substantial improvements in access to life-saving antiretroviral therapy (ART). Now, with improved survival, people living with HIV (PLWH) are at increased risk for non-communicable diseases (NCDs), including atherosclerotic cardiovascular disease (CVD). We assessed the existing literature regarding the association of CVD outcomes and HIV in SSA.

Methods

We used the PRISMA guidelines to perform a systematic review of the published literature regarding the association of CVD and HIV in SSA with a focus on CVD surrogate and clinical outcomes in PLWH.

Results

From January 2000 until March 2017, 31 articles were published regarding CVD outcomes among PLWH in SSA. Data from surrogate CVD outcomes (n = 13) suggest an increased risk of CVD events among PLWH in SSA. Although acute coronary syndrome is reported infrequently in SSA among PLWH, limited data from five studies suggest extensive thrombus and hypercoagulability as contributing factors. Additional studies suggest an increased risk of stroke among PLWH (n = 13); however, most data are from immunosuppressed ART-naïve PLWH and thus are potentially confounded by the possibility of central nervous system infections.

Conclusions

Given ongoing gaps in our current understanding of CVD and other NCDs in PLWH in SSA, it is imperative to ascertain the burden of CVD outcomes, and to examine strategies for intervention and best practices to enhance the health of this vulnerable population.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4940-1) contains supplementary material, which is available to authorized users.

Farnesyltransferase inhibitors prevent HIV protease inhibitor (lopinavir/ritonavir)-induced lipodystrophy and metabolic syndrome in mice

Highly active antiretroviral therapy (HAART) has successfully reduced the mortality rate of patients with human immune deficiency virus (HIV) and HIV protease inhibitors (HIV PIs) are key components of HAART. Complications of HAART, particularly those associated with HIV PIs including lipodystrophy and metabolic disturbance, have emerged as an important public health issue. No specific treatment is available to prevent and/or treat HIV PI-associated lipodystrophy and metabolic syndrome. The present study demonstrated that a relatively low-dose of farnesyltransferase inhibitor (FTI), tipifarnib (3 mg/kg/day, subcutaneous injection) and lonafarnib (5 mg/kg/day, subcutaneous injection), prevented the onset of lipodystrophy and metabolic syndrome induced by the combination of two HIV PIs, lopinavir (50 mg/kg/day, intraperitoneal injection) and ritonavir (12.5 mg/kg/day, intraperitoneal injection), in mice. Consistent with previous studies, treatment with lopinavir/ritonavir for 2 weeks decreased body weight, adipose tissue mass, levels of plasma adiponectin and leptin, and increased plasma levels of triglycerides, total cholesterol and insulin. Tipifarnib and lonafarnb prevented or ameliorated all of these alterations in the HIV PI-treated mice. These data identify FTIs as a novel potential strategy to prevent or treat HIV PI-associated lipodystrophy and metabolic syndrome in HIV-infected patients on HAART.

HIV infection, antiretroviral therapy, and measures of endothelial function, inflammation, metabolism, and oxidative stress

Background

HIV-infected patients have an increased risk of cardiovascular disease (CVD). Impaired endothelial function is an early risk factor for CVD in the general population. It is presumed that HIV infection is associated with impaired endothelial function, but results have been inconsistent.

Objectives

Our objectives were to determine the relationships between HIV infection, virologic suppression with antiretroviral therapy (ART), in vivo measures of conduit artery and microvascular endothelial function, and circulating biomarkers of pathways associated with CVD.

Methods

We performed a cross-sectional analysis of three prospectively enrolled groups from a single center: 28 were HIV-infected and virologically-suppressed on a regimen of FTC/TDF/EFV (HIV+ART+), 44 were HIV-infected but not on ART (HIV+ART-), and 39 were HIV-uninfected healthy volunteers (HIV-) matched to the HIV+ART- group for age, sex, smoking status, and height. None had diabetes, uncontrolled hypertension, known CVD, or other pro-inflammatory condition. Flow mediated dilation (FMD), nitroglycerin-mediated dilation (NTGMD), reactive hyperemia velocity time integral (RHVTI), and FMD/RHVTI of the brachial artery were measured, as well as circulating biomarkers of systemic inflammation, metabolism, oxidative stress, and endothelial activation.

Results

No significant differences were found amongst the three groups in FMD (P = 0.46), NTGMD (P = 0.42), RHVTI (P = 0.17), and FMD/RHVTI (P = 0.22) in unadjusted comparisons. Adjusted ANOVA models which included brachial artery diameter, demographics, and conventional CVD risk factors did not appreciably change these findings. In pairwise comparisons, the HIV+ART- group had significantly higher soluble tumor necrosis factor receptor II, soluble CD163, β-2 microglobulin, interferon-γ- induced protein-10, tissue inhibitor of metalloproteinase-1, and vascular cell adhesion molecule-1 compared to the other two groups (all p<0.05). Correlates of endothelial function differed between study groups.

Conclusion

Although untreated HIV infection was associated with elevated levels of several biomarkers of inflammation and endothelial activation, we were unable to demonstrate differences in measures of conduit artery and microvascular endothelial function in this study population.

Pre-clinical carotid atherosclerosis and sCD163 among virally suppressed HIV patients in Botswana compared with uninfected controls

Objectives

Human immune deficiency virus (HIV) is associated with increased cardiovascular disease (CVD) risk, yet the relationship between HIV and carotid atherosclerosis / monocyte activation among virally suppressed HIV-infected patients in sub-Saharan Africa is not well understood.

Methods

We measured traditional CVD risk factors, bilateral distal common carotid intima media thickness (cIMT), presence of carotid plaque and plasma sCD163 levels among virally suppressed HIV-infected adults and HIV-uninfected controls, in a cross-sectional study in Gaborone, Botswana. The associations between HIV status, traditional CVD risk factors, sCD163 and outcome of cIMT were assessed in univariate and multivariate linear regression models.

Results

We enrolled 208 HIV-infected adults (55% Female, mean age 39 years) who had undetectable HIV-1 RNA on antiretroviral therapy and 224 HIV-uninfected controls (47% Female, mean age 37 years). There was no difference in cIMT between study groups, with mean cIMT 0.607mm and 0.599mm in HIV-infected and HIV-uninfected, respectively (p = 0.37). Plasma sCD163 was significantly higher in HIV-infected versus HIV-uninfected persons (1917ng/ml vs 1593ng/ml, p = 0.003), but was not associated with cIMT (p = 0.43 among all, p = 0.72 for HIV-infected only). In the final multivariate model, increased cIMT was associated with older age, being treated for hypertension, and higher non-HDL cholesterol among all (p<0.001, p = 0.03, p<0.001 respectively), and with older age and waist-hip ratio in HIV-infected participants (p = 0.02 & p = 0.02 respectively). Carotid plaque was present in a significantly higher proportion of HIV-infected adults (RR 2.15, 95% CI 1.22, 3.81).

Conclusions

HIV-infected participants aged 30–50 years who have achieved viral suppression did not have increased cIMT when compared to HIV-uninfected controls in Botswana. However, well-controlled HIV was associated with excess monocyte activation. Future work should explore the impact of subclinical atherosclerosis on CVD events among HIV-infected and -uninfected adults in Botswana.

HIV infection and aortic stiffness

People living with human immunodeficiency virus (HIV) infection and receiving antiretroviral therapy now have the same life expectancy as the general population. However, they have a higher risk of atherosclerotic cardiovascular events because of a complex and polyfactorial vasculopathy, combining the effects of antiretroviral therapy, the HIV virus itself, immune activation, chronic inflammation and metabolic disturbances. Whether people living with HIV infection experience increased vascular aging compared with the general population remains controversial. To summarize current knowledge of the association between HIV infection and aortic stiffness as a marker of vascular aging. This review included 18 clinical studies in adult populations, published between 2009 and 2016, and identified on PubMed/MEDLINE or other databases. Search terms were aortic stiffness, arterial stiffness, vascular aging, pulse wave velocity and HIV. All 18 studies were observational, and compared groups infected (HIV+) and not infected (HIV-) with HIV. Ten studies (55%) reported no significant differences in aortic stiffness between HIV+ groups and age-matched HIV- control groups. The main reported determinants of aortic stiffness were age, blood pressure, smoking, metabolic syndrome and HIV-related variables, including CD4/CD8 ratio, current T-CD4 count < 200/mm³ and nadir T-CD4+ count < 200/mm³. We found discordant results regarding whether HIV+ patients had increased aortic stiffness compared with HIV- controls. However, HIV-related conditions were associated with vascular health. This association has been confirmed in recent prospective studies. There is emerging evidence that HIV itself and immune activity affect vascular health and the large arteries.

Association between Immune Markers and Surrogate Markers of Cardiovascular Disease in HIV Positive Patients: A Systematic Review

Background

HIV infection is associated with an increased risk of cardiovascular disease (CVD). Chronic low-grade immune activation is likely one of the driving mechanisms. This systematic review provides an overview of the evidence addressing the relation between immune markers and surrogate markers of CVD (except CIMT) in HIV infection.

Methods

A systematic search was performed in PubMed, Embase and Cochrane Library identifying all articles from 1996 to April 2015. It addressed the relation between immune markers and surrogate markers of CVD (except Carotid Intima-media Thickness) in HIV-positive adults. Two authors, using predefined criteria, independently conducted the selection of articles, critical appraisal and extraction of the data. Analysis focused on immune markers that were assessed most frequently. The review was conducted according to the PRISMA guideline and performed as part of an overarching review registered with PROSPERO (CRD42014010516).

Findings

Twenty-nine articles were selected, describing 34 immune markers and nine different CVD surrogate outcomes: coronary calcium score (13 times) and flow-mediated dilation (10 times) were used most frequently. Twenty-seven studies had a cross-sectional design. CRP, IL-6 and sVCAM-1 were assessed most frequently. None of the immune markers were clearly associated with any of the surrogate CVD outcomes. No effect estimate could be calculated due to marked heterogeneity in study populations, immune markers, outcomes and statistical approaches.

Interpretation

This review could not identify a clear association between any of the immune markers and surrogate CVD outcomes. This may reflect a true lack of association, or may be explained by heterogeneity across studies and lack of follow-up data. Future research should focus on longitudinal studies measuring a select set of immune markers and surrogate CVD outcomes awaiting the primary outcome of clinical cardiovascular events.

Efavirenz and ritonavir-boosted lopinavir use exhibited elevated markers of atherosclerosis across age groups in people living with HIV in Ethiopia

BACKGROUND

HIV patients on highly-active antiretroviral therapy (HAART) have shown elevated incidence of dyslipidemia, lipodystrophy, and markers of cardiovascular disease. Evidence is beginning to emerge that implicates efavirenz (EFV) as a potential mediator of early on-set cardiovascular disease.

METHODS

Pediatric and adult HIV-infected HAART-naïve, EFV-treated, nevirapine (NVP)-treated, and ritonavir-boosted lopinavir (LPV/r)-treated subjects were recruited from Black Lion Hospital in Addis Ababa, Ethiopia. Pulse wave velocity (PWV), carotid intima-media thickness (cIMT), carotid arterial stiffness, brachial artery flow-mediated dilation (FMD), body mass index, waist-to-hip circumference ratio, and skinfold thickness were measured. CD4+ cell count, fasting glucose, lipoprotein profiles and triglycerides were also determined. Results were segmented into pediatric (6-17 years of age), young adults (25-39 years old) and older adults (40-60 years old).

RESULTS

PWV was generally elevated in EFV- and LPV/r-treated subjects compared to NVP-treated subjects across age groups. cIMT was elevated in EFV- and LPV/r-treated compared to NVP-treated older adults and in EFV-treated compared to HAART-naïve older adults. FMD was impaired in EFV- and LPV/r-treated compared to HAART-naïve younger adults, in EFV-treated compared to NVP-treated young and older adults, and in LPV/r-treated compared to NVP-treated older adults. Differences in lipoprotein profiles and skinfold thickness with HAART regimen were observed in pediatric and young adults, but less so in older adults.

CONCLUSIONS

Whereas LPV/r and other protease inhibitors have long been recognized as mediators of HIV/HAART-associated atherosclerosis, this report supports the emerging evidence that EFV may also mediate cardiovascular disease in people living with HIV on HAART.

Serum amyloid P (SAP) is associated with impaired brachial artery flow-mediated dilation in chronically HIV-1 infected adults on stable antiretroviral therapy

OBJECTIVE

This study aimed to evaluate the relationship between inflammatory biomarkers and endothelial dysfunction (ED), as measured by brachial artery flow-mediated dilation (FMD).

METHODS

We conducted a cross-sectional analysis utilizing baseline data of 135 participants with HIV infection on stable antiretroviral therapy (ART) in the Hawaii Aging with HIV-Cardiovascular (HAHC-CVD) study who had available baseline inflammatory biomarkers and brachial artery FMD measurements.

RESULTS

We observed significant associations between brachial artery FMD and baseline brachial artery diameter, age, male gender, traditional cardiovascular disease (CVD) risk factors such as BMI, waist to hip ratio, hypertension, systolic blood pressure (BP), diastolic BP, and LDL cholesterol, and 10-year coronary heart disease (CHD) risk estimated by Framingham risk score (FRS). Of all biomarkers tested, higher level of C-reactive protein (CRP) (beta =  - 0.695, P = 0.030) and serum amyloid P (SAP) (beta =  - 1.318, P = 0.021) were significantly associated with lower brachial artery FMD in univariable regression analysis. After adjusting for baseline brachial artery diameter, age, and selected traditional CVD risk factors in multivariable model, SAP remained significantly associated with brachial artery FMD (beta =  - 1.094, P = 0.030), while CRP was not (beta =  - 0.391, P = 0.181).

DISCUSSION

Serum amyloid P was independently associated with impaired brachial artery FMD and may potentially relate to ED and increased CVD risk in HIV-infected patients on stable ART.

Efavirenz treatment causes arterial stiffening in apolipoprotein E-null mice

The development of highly active antiretroviral therapy (HAART) has transformed HIV-1 infection from a terminal diagnosis to a chronic, yet manageable disease. However, people living with HIV-1 exhibit a host of non-AIDS-related co-morbidities including cardiovascular disease (CVD). Several HAART drugs have been implicated in the development of CVD; however, the role of efavirenz (EFV), a highly prescribed HAART drug, in early-onset CVD is poorly understood. We treated apolipoprotein E-null (ApoE(-/-)) mice with EFV (75 mg/kg/day) or vehicle, via oral gavage, for 35 days and quantified commonly measured preclinical markers of CVD (intima-media thickening, arterial stiffening) and plaque area. Suprarenal abdominal aortas were subjected to cylindrical biaxial biomechanical testing and standard histology. Aortas from EFV-treated mice demonstrated decreased compliance (i.e., increased arterial stiffness) and decreased axial force and a trend toward decreased in vivo axial stretch, but EFV treatment had no effect on intima-media thickness of the aortic wall or plaque coverage in thoracic aortas and aortic arches. Taken together, these data suggest that EFV leads to arterial stiffening but, for the dose and duration tested, did not lead to elevated plaque progression in ApoE(-/-) mice.