Chris T. Longenecker, MD

We have limited data to date on disparities in care for people living with HIV compared with uninfected persons in the United States with regard to the management of CVD and CVD prevention. A highly cited paper from Joseph A. Ladapo, MD, PhD, several years ago from UCLA (Ladapo JA, et al. J Am Heart Assoc. 2017;doi:10.1161/JAHA.117.007107) highlighted the fact that people living with HIV tend to be prescribed prevention therapies such as aspirin, statins, etc, at lower rates compared with HIV-uninfected persons. This has led to the realization that we need to explore the reasons behind these disparities and develop interventions to address disparities in care for people living with HIV.

This study extends the Ladapo study and others by showing that there are disparities in post-ACS care for people with HIV. In particular, the rates of cholesterol-lowering medicines and statins for people who have had ACS should be 100% for secondary prevention, and it is only 67% in this study among people with HIV.

The reasons for that are not clear from this study, which is a 30,000-foot view of the issue, but you could think of many reasons, one of them being cardiologists’ lack of familiarity with the interactions antiretroviral drugs may have with statins. There are probably many other reasons as well.

Disparities in care are well documented across many different populations of at-risk persons in the United States. For people living with HIV, cardiologists and others who are less familiar with these patients need to be more aggressive and attuned to the fact that people are now living long and healthy lives and should be optimally treated to prevent CVD. To do so requires reaching out to the infectious disease doctors and others caring for these patients to make sure that therapies are appropriate, that drug interactions don’t exist or that the potential for adverse effects are considered. It’s definitely possible and we need to do a better job.

From a research perspective, we need to understand better the specific reasons behind these disparities. That requires qualitative and mixed methods research to understand why people with HIV are not being prescribed these therapies or why they’re not taking them. Using that research, we need to develop interventions to reduce disparities with implementation science approaches. There’s a large NIH effort called the PRECLUDE Consortium, which is attempting to do this for primary prevention of CVD in people living with HIV. This study highlights the need for better secondary prevention for people living with HIV who experience a CV event.