Human Immunodeficiency Virus and Heart Failure in Low- and Middle-Income Countries

Abstract

Successful combination therapy for human immunodeficiency virus (HIV) has transformed this disease from a short-lived infection with high mortality to a chronic disease associated with increasing life expectancy. This is true for high- as well as low- and middle-income countries. As a result of this increased life expectancy, people living with HIV are now at risk of developing other chronic diseases associated with aging. Heart failure has been common among people living with HIV in the eras of pre- and post- availability of antiretroviral therapy; however, our current understanding of the pathogenesis and approaches to management have not been systematically addressed. HIV may cause heart failure through direct (e.g., viral replication, mitochondrial dysfunction, cardiac autoimmunity, autonomic dysfunction) and indirect (e.g., opportunistic infections, antiretroviral therapy, alcohol abuse, micronutrient deficiency, tobacco use) pathways. In low- and middle-income countries, 2 large observational studies have recently reported clinical characteristics and outcomes in these patients. HIV-associated heart failure remains a common cardiac diagnosis in people living with heart failure, yet a unifying set of diagnostic criteria is lacking. Treatment patterns for heart failure fall short of society guidelines. Although there may be promise in cardiac glycosides for treating heart failure in people living with HIV, clinical studies are needed to validate in vitro findings. Owing to the burden of HIV in low- and middle-income countries and the concurrent rise of traditional cardiovascular risk factors, strategic and concerted efforts in this area are likely to impact the care of people living with HIV around the globe.

Association Between HIV Infection and the Risk of Heart Failure With Reduced Ejection Fraction and Preserved Ejection Fraction in the Antiretroviral Therapy Era

“…45 Globally, HF is common in low-income and middle-income countries, where the burden of HIV is high and availability of ART can be limited. 46 Given these facts, health care professionals should focus on guideline-recommended HIV treatment and HF risk factor prevention (including diabetes, hypertension, renal disease, smoking, alcohol abuse and dependence, and obesity), as well as screening for HIV in individuals with new-onset HF where appropriate. 25 Developing tools designed to risk stratify HIV-infected individuals for HF will also be required.…”

HIV Infection and Risk of Cardiovascular Diseases Beyond Coronary Artery Disease

“…In low-to-middle income countries, systolic HF remains a more important contributor to the CVD burden in PLWH, even as access to ART expands [26]. On the other hand, studies have suggested that HIV+ patients with HF are less likely to be optimally treated with antiplatelet drugs, statins, diuretics, and angiotensin-converting enzyme inhibitors/aldosterone receptor blockers (ARBs; p < 0.0001 for all comparisons) compared to uninfected patients with heart failure [4, 5].…”

Enfermedad cardiovascular y metabólica en pacientes infectados por el virus de la inmunodeficiencia humana

“…Sin embargo, la compresión de la patogénesis de este proceso no se ha abordado de manera sistemática en estudios 23 . Hay diversas hipótesis que pueden ser sugestivas de este proceso de afección, entre estas están: replicación viral, infecciones oportunistas, influencia antirretroviral, entre otras causas.…”

“…Las tasas de mortalidad hospitalaria, en dos países africanos, por falla cardíaca asociada a VIH alcanzaron el 15% para el año 2007 24,25 . En dos grandes estudios observacionales realizados en países de ingresos bajos y medios se informó que la falla cardíaca asociada a VIH aún es un diagnóstico muy común en estos pacientes siendo necesario una intervención más temprana 2,23,26,27 . Una hipótesis implica la toxicidad miocárdica directa viral, donde el ácido ribonucleico del VIH en altas concentraciones, es decir más de 500 copias por mL de sangre, se asocia con cerca de 2,5 veces más probabilidad de desarrollar falla cardiaca en comparación con individuos no infectados 27 .…”