Proactive Steps Needed to Address High Burden of Cardiovascular Disease in People Living With HIV
The health of people living with HIV who get tested, are in care and adhere to treatment has dramatically improved with minimal risk of AIDS-related complications. Indeed, today's first-line HIV treatments are potent, very well tolerated and rarely associated with serious toxicity -- allowing individuals to have an excellent quality of life. In this setting, focus is appropriately shifting to long-term health risks for people with HIV.
Among these concerns, it's been known for some time that people with HIV have more frequent cardiovascular disease (CVD), including heart attacks and stroke. A myriad of reasons have been proposed for this, including both HIV-related and traditional factors (such as tobacco smoking, high blood pressure or diabetes).
Our own work with the Centers for Disease Control and Prevention HIV Outpatient Study showed that a significant risk factor in developing CVD is having a low pre-treatment CD4 cell count. Others have shown that hepatitis C virus coinfection is a risk factor for CVD among people with HIV.
Among traditional risk factors, emerging data suggest that people with HIV are particularly at risk of tobacco's negative effects, having greater risk of heart attacks than HIV-negative people who smoke, and the majority of heart attacks in people living with HIV may be attributable to smoking tobacco.
Appreciating that the life expectancy of people with HIV who have access to care and treatment is approaching normal, it is of special interest to estimate the burden of CVD in the HIV-positive population. A new study looks at this question by comparing simulated populations of people: the U.S. general population, HIV-negative people at-risk for HIV, and people with HIV. The second is a particularly relevant group to compare with, since many people with HIV have increased rates of CVD risk factors, such as tobacco smoking or hepatitis C virus infection. The analysis looked at rates of CVD cases (both pre-existing and new events) and their effect on survival and death. For the HIV-positive population, the investigators assumed a relatively young average age of 36, pre-treatment CD4 count of 351 and adherence to antiretroviral treatment with a current CD4 of 751.
The study results suggest that life expectancy for people with HIV approaches that of HIV-negative, at-risk individuals (70 versus 76 years for males; 67 versus 73 years for females), but there is still an estimated difference of about six years. For new cases of CVD ("incident cases"), People living with HIV were at greatest risk, with an estimated 21% of males and 14% of females affected by age 60. Male individuals with HIV had lifelong increased CVD risk compared with the general population, but it decreased for females over the age of 70, when the risk in the general population increased. Overall, 65% of male and 44% of female individuals with HIV were projected to have a lifetime risk of CVD.
This study reinforces the important health risk of CVD for people living with HIV. The authors estimate that, even with successful antiretroviral therapy, nearly one in two individuals with HIV may have CVD in their lifetimes -- a risk greater than in either the general population or HIV-negative, at-risk people. Indeed, the increased CVD risk in people with HIV is comparable with the effect of diabetes.
The study has several important implications. While getting tested (preferably early), getting on and adhering to modern antiretroviral therapy, and achieving durable HIV viral load suppression are the first critical steps toward improving health and quality of life for people living with HIV, we must all (policy makers, care providers, educators and people with HIV) fully appreciate how commonly the serious health implications of CVD can impact the lives of people with HIV.
For people with HIV, this means talking with your doctor to address the following:
- Assessing CVD risk and risk factors.
- Changing behavioral risk factors such as tobacco smoking, diet and exercise.
- Diagnosing and treating underlying health risks (such as diabetes or high blood pressure).
- Curing hepatitis C virus infection.
Given the important role that tobacco smoking plays in CVD risk, you and your doctor should prioritize quitting smoking. While completely quitting tobacco remains a laudable goal, reducing tobacco use is also considered a good thing and should not be seen as a failure.
Long, healthy life is possible for people living with HIV who have access to care, but CVD may negatively affect that prospect for many. Proactive steps to deal with CVD prevention and harm reduction should help reduce the burden of CVD for people living with HIV in the future.
Benjamin Young, M.D., Ph.D., is senior vice president and chief medical officer of the International Association of Providers of AIDS Care (IAPAC) and provides care for people living with HIV at APEX Family Medicine in Denver.