HIV infection as vascular risk: A systematic review of the literature and meta-analysis

Abstract

ImportanceThe vascular risk attributable to HIV infection is rising. The heterogeneity of the samples studied is an obstacle to understanding whether HIV is a vascular risk across geographic regions.ObjectiveTo test the hypothesis that HIV infection is a vascular risk factor, and that the risk conferred by HIV varies by geographical region.Data sourcesA systematic search of publications was carried out in seven electronic databases: PubMed, The Cochrane Library, EMBASE, Web of Science, LILACS, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform from inception to July 2015.Study selectionWe included longitudinal studies of HIV+ individuals and their risk of vascular outcomes of ≥ 50 HIV+ cases and excluded studies on biomarkers of vascular disease as well as clinical trials.Data extraction and synthesisData was extracted by one of the authors and independently confirmed by the other two authors. We used incidence rate (IR), incidence risk ratio (IRR) and hazard ratio (HR) with their 95% confidence intervals as measures of risk.Main outcomeAll-death, myocardial infarction (MI), coronary heart disease (CHD), any stroke, ischemic stroke (IS) or intracranial hemorrhage (ICH).ResultsWe screened 11,482 references for eligibility, and selected 117 for analysis. Forty-four cohorts represented 334,417 HIV+ individuals, 49% from the United States. Compared with their European counterparts, HIV+ individuals in the United States had higher IR of death (IRR 1.78, 1.69–1.88), MI (IRR 1.61, 1.29–2.01), CHD (IRR 2.27, 1.92–2.68), any stroke (IRR 1.94, 1.59–2.38), IS (IRR 1.56, 1.23–1.98), and ICH (IRR 4.03, 2.72–6.14). Compared with HIV- controls and independent of geographical region, HIV was a risk for death (HR 4.77, 4.55–5.00), MI (HR 1.60, 1.49–1.72), any CHD (HR 1.20, 1.15–1.25), any stroke (HR 1.82, 1.53–2.16), IS (HR 1.27, 1.15–1.39) and ICH (HR 2.20, 1.61–3.02). Use of antiretroviral therapy was a consistent risk for cardiac outcomes, while immunosuppression and unsuppressed viral load were consistent risks for cerebral outcomes.ConclusionsHIV should be considered a vascular risk, with varying magnitudes across geographical and anatomical regions. We think that strategies to reduce the HIV-related vascular burden are urgent, and should incorporate the disparities noted here.

Characteristics of hypertension among people living with HIV in Ghana: Impact of new hypertension guideline

“…People living with HIV (PLWH) infection are at a heightened risk of major adverse cardiovascular events (MACE) than uninfected persons . The accentuated cardiovascular disease (CVD) risk in HIV has been attributed to the persistent immune activation and inflammation from HIV infection, pro‐atherogenic lipid abnormalities induced by HIV infection, and combination antiretroviral therapy (cART) .…”

“…Overall, a recent meta‐analysis of worldwide data found 35% of PLWH on cART had hypertension compared with 30% among PLWH who were not on cART . Of note, PLWH with hypertension have a higher risk of MACE and increased all‐cause mortality relative to HIV‐infected adults with normal blood pressure or HIV‐uninfected population with hypertension . There is a dearth of studies with a focus on assessing the risk factors for hypertension among PLWH on cART compared with PLWH who are cART‐naive in SSA.…”

“…19 Of note, PLWH with hypertension have a higher risk of MACE and increased all-cause mortality relative to HIV-infected adults with normal blood pressure or HIV-uninfected population with hypertension. 1,20 There is a dearth of studies with a focus on assessing the risk factors for hypertension among PLWH on cART compared with PLWH who are cART-naive in SSA. Moreover, most of the studies evaluating the burden of hypertension among PLWH were performed before the recent American College of Cardiology/ American Heart Association revised definitions for hypertension with lower blood pressure thresholds.…”

Motor function declines over time in human immunodeficiency virus and is associated with cerebrovascular disease, while HIV-associated neurocognitive disorder remains stable

“…Similarly, investigations of HAND must now consider the increasingly important effects of non-infectious comorbidities, particularly, cerebrovascular disease. HIV itself has been shown to be an independent risk factor for cerebrovascular disease (Gutierrez et al 2017) and is estimated to be one of the most important causes of death in the CART-era HIV population (Braithwaite et al 2005). …”

Fixed‐dose combination therapy to reduce the growing burden of cardiovascular disease in low‐ and middle‐income countries: feasibility and challenges

“…Approximately 80% of worldwide CVD‐related deaths arise from LMICs, where it is expected that the condition will surpass communicable diseases as the leading cause of death by 2030 . This high burden of CVD in developing countries is attributable to changes in lifestyle (including poor dietary habits and lack of physical activity) and rapid urbanization, collectively with a sharp increase in CVD risk factors such as hypertension, dyslipidemia, obesity, diabetes mellitus, HIV infection, and air pollution . CVD carries a huge economic burden especially in LMICs, where it often occurs at a younger age, thus having a greater effect on loss of income during productive years .…”