People living with HIV face premature heart disease and barriers to care
American Heart Association scientific statement
DALLAS, June 3, 2019 — Effective antiretroviral therapy has changed the human immunodeficiency virus (HIV) from a progressive, fatal disease to a chronic, manageable condition that is associated with higher rates of heart attacks, strokes, heart failure, sudden cardiac deaths, and other diseases compared to people without HIV, according to a new scientific statement from the American Heart Association published in the Association journal Circulation.
People living with HIV are at increased risk of heart and blood vessel diseases because of interactions between traditional risk factors, such as diet, lifestyle and tobacco use, and HIV-specific risk factors, such as a chronically activated immune system and inflammation characteristic of chronic HIV.
Tobacco use, a major risk factor for cardiovascular diseases, is common among people living with HIV. In a nationally representative U.S. sample, 42% of people living with HIV were current smokers. Heavy alcohol use, substance abuse, mood and anxiety disorders, low levels of physical activity and poor cardiorespiratory fitness are also common among people living with HIV and may contribute to elevated risk for diseases of the heart and blood vessels, according to the statement.
“Considerable gaps exist in our knowledge about HIV-associated diseases of the heart and blood vessels, in part because HIV’s transition from a fatal disease to a chronic condition is relatively recent, so long-term data on heart disease risks are limited,” said Matthew J. Feinstein, M.D., M.Sc., chair of the writing group for the statement and assistant professor of medicine and preventive medicine at the Feinberg School of Medicine, Northwestern University in Chicago, Illinois.
In addition, people living with HIV are often stigmatized and face significant barriers to optimal health care, such as education level, where they live, healthcare literacy, disenfranchisement from the healthcare system, cognitive impairment, injection drug use, internalized and anticipated stigma, gait and mobility impairment, frailty, depression and social isolation. There are also disparities in care based on age, race, ethnicity and gender.
Another area of concern is the aging population of people living with HIV – 75% of people living with HIV are over age 45. “Aging with HIV differs greatly from the aging issues facing the general population,” said Jules Levin, M.S., in an accompanying patient perspective. Levin has been living with HIV for 35 years and is the founder and executive director of the National AIDS Treatment Advocacy Project.
“On average, people living with HIV who are over 60 years old have 3-7 medical conditions, including heart attacks, strokes, heart failure, kidney disease, frailty and bone diseases and many take 12-15 medications daily. As they age, people living with HIV are often alone and disabled, emotionally homebound due to depression, and are socially isolated. In addition, they often suffer from lack of mobility and an impaired ability to perform normal daily functions. We urgently need better awareness and more patient-focused research and care efforts for this vulnerable population,” said Levin.
Providing scientifically based recommendations on how to reduce the risk of cardiovascular disease among people living with HIV is also challenging. “There is a dearth of large-scale clinical trial data on how to prevent and treat cardiovascular diseases in people living with HIV. This is an area of research that is needed for informed decision-making and effective CVD prevention and treatment in the aging population of people living with HIV,” said writing group chair Feinstein.
To assess a person living with HIV’s cardiovascular risk, the statement advises a nuanced approach. This approach includes quantifying traditional heart disease risk factor burden using tools such as American Heart Association/American College of Cardiology Atherosclerotic Disease Risk Calculator, which estimates a person’s ten-year risk of having a heart attack, stroke or other cardiovascular condition, as a starting point. However, the authors caution that people living with HIV may have a higher risk than indicated by the calculator. Additional considerations that should be factored into the heart disease risk assessment include family history of heart disease and HIV-specific factors, such as whether or not a patient started antiretroviral therapy soon after diagnosis.
To keep people living with HIV healthy, Feinstein emphasizes the importance of a healthy lifestyle that includes smoking cessation, adequate physical activity, eliminating or reducing the amount of alcohol consumed and a healthy diet. In addition, medications such as statin drugs, which lower cholesterol, and other medications that make blood less likely to form clots may be helpful, although more clinical trial data are needed.
Co-authors: Priscilla Y. Hsue, M.D., vice chair; Laura Benjamin, Ph.D.; Gerald S. Bloomfield, M.D., MPH; Judith S. Currier, M.D.; Matthew S. Freiberg, M.D., M.Sc.; Steven K. Grinspoon, M.D.; Jules Levin, M.S.; Chris T. Longenecker, M.D.; and Wendy S. Post. M.D., M.S.
After June 3, view the manuscript and patient perspective online.
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