"I had no idea that since I have HIV, I may be twice as likely to have a heart event compared to the general population," said Frank Carroll, a 63-year-old man who has been living with HIV for over two decades.
Unfortunately, that is the case for the majority of people who are living with HIV. Up to this point, there has been very little research conducted regarding heart disease and HIV, but here is what we do know:
People with HIV often have what is known as "inflamed non-calcified plaque" buildup in the heart. This plaque is considered "high risk" plaque because it is a leading risk factor for heart disease. This is important to know because "inflamed non-calcified plaque" is extremely vulnerable to rupture and that can lead to a sudden heart event, such as a heart attack. Traditional risk factors, including high blood pressure and high cholesterol, are well-known contributors to heart disease for those with HIV and the general population. However, an additional and significant HIV-related risk factor for developing heart disease is constant activation of the immune system; this happens even with antiretroviral therapy and when the virus is undetectable.
Heart disease rates among people living with HIV are elevated compared to the general population. If you add to that the fact that heart disease is often a silent killer with atypical symptoms, it is easy to understand why more research needs to be conducted on this subject.
It is important that health care providers gain a better understanding of the intersection of HIV and heart disease to inform how they educate, treat, and monitor patients. It is equally important that heart disease prevention tools are developed and tested, specifically among people living with HIV, to determine the most effective ways to treat and prevent heart disease events in these patients.
"We know that people with HIV are living longer and aging. The HIV community has worked very hard for these successes; they have participated in research studies for the past 30 years to help develop antiretroviral therapy that works to suppress HIV. It is our goal now to find ways to keep people with HIV healthy as they age and help them achieve a full and healthy lifespan," said Dr. Steven K. Grinspoon, Director of Massachusetts General Hospital Program in Nutritional Metabolism and Professor of Medicine at Harvard Medical School.
Gaining a better understanding of how HIV may contribute to heart disease and determining effective prevention strategies will enable health care providers and patients to act before significant damage and co-morbidities develop. The time to take action is now, before this silent killer strikes.
Be Proactive About Heart Health
"I never really thought I would live to be an old man, so it was not until a few years ago that I made the decision to take control of my overall health. I quit smoking and am now more conscious of my diet and exercise activities than in the past. Research has come a long way in helping people with HIV, but there are many things we can do as patients to help ourselves as well," said Mr. Carroll.
Members of the HIV community should make it a priority to talk with their health care provider about additional ways to remain heart healthy. There are always helpful resources available at local HIV clinics such as smoking cessation programs, exercise groups, nutrition services, and research studies.
A "whole-body" approach to living longer with HIV is critical. HIV patients and their health care providers alike should understand that there are many pieces to the puzzle when it comes to keeping those living with HIV heart healthy.
"I have treated many patients who were overweight, who smoked, and rarely exercised. In these instances, I always made it a point to explain the risk factors associated with heart disease and the concerns regarding inflamed non-calcified plaque unique to the HIV population. In future visits, many of these patients made lifestyle changes that, in the long run, led to increasingly positive health outcomes," said Dr. Grinspoon.
Although smoking cessation, eating a healthy diet, and exercising are excellent ways to stay healthy, clearly, there are more tools needed to prevent heart disease among people living with HIV.
Given their increased risk of cardiovascular disease, people living with HIV need to be proactive when it comes to heart health. It is important that they follow dietary and exercise guideline recommendations to keep their heart healthy. Among the recommendations:
- Eat a variety of fruits and vegetables
- Eat fats from plant-based foods instead of animals (i.e., eat nuts instead of cheese)
- Avoid excess sugar
- Do some sort of physical activity most days of the week
- Quit smoking
Could Statins Be the Ideal Heart Disease Prevention Tool?
"Recent studies show that statins may reduce immune activation and shrink dangerous plaques in the blood vessels in the heart. Statins may therefore be a potentially useful treatment to prevent heart disease in the HIV population," said Dr. Grinspoon.
Statin medications are a validated strategy with the potential to prevent heart disease, and target traditional and nontraditional risks in people living with HIV. In small studies examining the effects of statins among HIV-positive study participants, statins significantly decreased low-density lipoprotein (LDL) cholesterol, a known risk factor for heart disease. Statins also reduced blood markers of immune activation, inflammation, and inflamed non-calcified plaque in the coronary arteries of these study participants.
However, at this time, it remains unknown if statins will prevent heart disease events in people living with HIV. Although statins have proven safe and are widely prescribed, it is not fully understood how they will be tolerated in the HIV population. For example, some studies suggest older statins may cause an increase in blood sugar. However, newer statins, broken down by the body differently than those in the past, have not been shown to cause an increase in blood sugar. In fact, a 2013 study explored the effects of a newer statin called pitavastatin in over 200 HIV-positive study participants and results proved there was no effect of pitavastatin related to increased blood sugar levels. This study was reassuring to researchers because it indicated that newer statins are well tolerated among people living with HIV.
Given the crucial need to find a heart disease prevention tool for the HIV community, investigators from the AIDS Clinical Trials Group (ACTG) Network and Massachusetts General Hospital sought funding from the National Institutes of Health (NIH) to conduct the largest heart disease prevention research study to date among people living with HIV.
About the REPRIEVE Trial
"I chose to participate in the REPRIEVE Trial because I want to do everything I can to prevent developing heart disease. It is also a way for me to give back to the researchers, the HIV community, and those amazing HIV study participants who came before me. Basically, it is a win-win situation for me," said Mr. Carroll.
The REPRIEVE (Randomized Trial to Prevent Vascular Events in HIV) Trial launched in April 2015 and will test whether pitavastain prevents heart disease events in people living with HIV. REPRIEVE study participants will be randomized to take one pill, once a day of pitavastatin or a placebo, for an average of 4-5 years. REPRIEVE will enroll 6,500 HIV-positive study participants who are considered to have low to moderate traditional known risk factors for developing heart disease, but are likely at an increased risk due to HIV. Trial sites are located throughout the United States, Canada, Thailand, South America, and Africa.
A unique aspect of REPRIEVE is that there are several sub-studies incorporated into the clinical trial design. In one of the sub-studies, study participants will have a picture of their heart vessels taken by a CT scanner; the picture will be taken before the study medication is started and two years after to see if there are changes in inflamed non-calcified plaque with pitavastatin. Other sub-studies will explore if, by decreasing inflammation, pitavastatin improves kidney function and measures of quality of life.
Women also have a special place in REPRIEVE. To encourage women's participation in REPRIEVE, there is a campaign just for women called Follow YOUR Heart. Follow YOUR Heart has an interactive website with helpful resources on HIV, heart disease, and women's health and was developed to focus on including and educating women living with HIV about the clinical research process.
Until we know the results of REPRIEVE, people with HIV should follow the important steps outlined to prevent heart disease, such as not smoking, exercising regularly, and eating nutritiously. People living with HIV need to talk to their health care provider about heart health and consider joining the REPRIEVE trial. Joining REPRIEVE is a way for patients to learn more about their own bodies, while helping to determine a successful prevention strategy for the greater HIV community.
Learn more about REPRIEVE; go to reprievetrial.org.
Kathleen Fitch, M.S.N., F.N.P., is the Project Manager for the Clinical Coordinating Center of the REPRIEVE Trial located at Massachusetts General Hospital. Kathleen has conducted several research studies that have increased the understanding of metabolic complications of HIV including lipodystrophy syndrome, diabetes, and cardiovascular disease. She has also explored different treatment strategies for these abnormalities, including lifestyle modification. In addition, she is a volunteer community educator at several HIV/AIDS service organizations throughout New England.