Association of HIV Infection and Incident Abdominal Aortic Aneurysm Among 143 001 Veterans

Abstract

BACKGROUND: People with HIV (PWH) have an increased risk of cardiovascular disease. Previous cross-sectional data suggest there is a higher prevalence of abdominal aortic aneurysm (AAA) in PWH than in those without HIV. Whether PWH have an increased risk of incident AAA compared with those without HIV is unknown. METHODS: We analyzed data among participants without prevalent AAA from the Veterans Aging Cohort Study, a prospective, observational, longitudinal cohort of veterans with HIV matched 1:2 with veterans without HIV infection. We calculated AAA rates by HIV status and assessed the association between HIV infection and incident AAA using Cox proportional hazards models. We defined AAA using the International Classification of Diseases, 9th or 10th revision, or Current Procedural Terminology codes and adjusted all models for demographic characteristics, cardiovascular disease risk factors, and substance use. Secondary analyses examined the association between time-varying CD4+ T-cell count or HIV viral load and incident AAA. RESULTS: Among 143 001 participants (43 766 with HIV), over a median follow-up of 8.7 years, there were 2431 incident AAA events (26.4% among PWH). Rates of incident AAA per 1000 person-years were similar among PWH (2.0 [95% CI, 1.9–2.2]) and people without HIV (2.2 [95% CI, 2.1–2.3]). There was no evidence that HIV infection increased the risk of incident AAA compared with no HIV infection (adjusted hazard ratio, 1.02 [95% CI, 0.92–1.13]). In adjusted analyses with time-varying CD4+ T-cell counts or HIV viral load, PWH with CD4+ T-cell counts <200 cells/mm 3 (adjusted hazard ratio, 1.29 [95% CI, 1.02–1.65]) or HIV viral load ≥500 copies/mL (adjusted hazard ratio, 1.29 [95% CI, 1.09–1.52]) had an increased risk of AAA compared with those without HIV. CONCLUSIONS: HIV infection is associated with an increased risk of AAA among those with low CD4+ T-cell counts or elevated HIV viral load over time.

Letter by Teng et al Regarding Article, “Association of HIV Infection and Incident Abdominal Aortic Aneurysm Among 143 001 Veterans”

“…We congratulate Filipkowski et al 1 on the recent publication of their article in Circulation . The authors comprehensively demonstrate that HIV infection is associated with an increased risk of abdominal aortic aneurysm (AAA) among those with low CD4+ T-cell counts or elevated HIV viral load over time.…”

“…In this excellent article, >98% of veterans receive their antiretroviral therapy from Veterans Affairs pharmacies. 1 However, some of the antiretroviral therapy regimens (eg, abacavir, lopinavir, and ritonavir) used had side-effect profiles detrimental to vascular homeostasis, such as altered glucose and lipid metabolism and mitochondrial toxicity. 4 We submit that whether the selection of antiretroviral therapy regimens also aggravates damage to abdominal aorta should be further assessed.…”

“…We share the views expressed by the authors in the article that people with HIV, particularly those who have higher viral load, may also experience molecular mimicry between HIV proteins and the aortic wall, leading to autoimmune-mediated aortic damage and direct invasion of the aortic wall by the virus, leading to extracellular matrix degradation. 1 Hepatitis C is a common co-infection among people with HIV. 4 What interests us is whether patients with HIV and COVID-19 may further exacerbate aortic damage, because COVID-19 can also cause the virus itself and cause immune system abnormalities.…”

Letter by Ren and Sun Regarding Article, “Association of HIV Infection and Incident Abdominal Aortic Aneurysm Among 143 001 Veterans”

“…We read with great interest the article by Filipkowski et al, 1 who revealed that there was no evidence that HIV infection increased the risk of incident abdominal aortic aneurysm (AAA) compared with no HIV infection. However, with time-varying CD4+ T-cell counts or HIV viral load, people with HIV with CD4+ T-cell counts <200 cells/mm 3 (adjusted hazard ratio, 1.29 [95% CI, 1.02-1.65]) or HIV viral load ≥500 copies/ mL (adjusted hazard ratio, 1.29 [95% CI, 1.09-1.52]) had an increased risk of AAA compared with those without HIV.…”