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Traditional interventions can prevent cardiovascular disease in patients with HIV
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Traditional methods for preventing cardiovascular disease can maximize cardiovascular health of patients with HIV and defray future health care costs, according to findings published in Clinical Infectious Diseases.
“This is the first time anyone has systematically compared the impact of different CVD prevention interventions on CVD burden in HIV-positive patients who are at risk because of both traditional and HIV-related factors,” Mikaela Smit, PhD, research associate in the department of infectious disease epidemiology, Imperial College London, told Infectious Disease News. “Our results demonstrated that a large proportion of adverse CVD events and treatment costs could be averted by intensified diagnosis and treatment of hypertension and dyslipidemia to close the gaps of undiagnosed and untreated cases.”
The researchers created an individual-based model of cardiovascular disease in 8,791 patients with HIV who were receiving ART, all of whom were included in the Dutch national AIDS Therapy Evaluation in the Netherlands, or ATHENA, cohort. The model followed patients with HIV as they aged and developed and then began treatment for CVD. Smit and colleagues evaluated four different prevention interventions: earlier diagnosis and treatment of HIV, avoiding combination ART in the presence of increased cardiovascular risk, smoking cessation and more intensive monitoring and treatment of dyslipidemia and hypertension.
Most baseline patients (77.9%) were male, and slightly more than half (52.5%) were men who have sex with men. The median age was 43.8 years. The model predicted a 55% increase in CVD among patients with HIV between 2015 and 2030, Smit and colleagues reported, while costs were predicted to rise by 36%. Smoking cessation had the potential to avert up to 13.1% of cases of CVD in the model, whereas intensified monitoring and treatment of hypertension could avert up to 20%. These traditional methods were significantly more effective than earlier HIV diagnosis and treatment, which could avert a projected 0.8% of cases, and avoiding combination ART with increased cardiovascular risk, which could avert 3.7% of cases, the researchers wrote.
Smit and colleagues added that targeting high-risk patients “could avert the majority of events and costs.”
“The good news is that such an intervention is highly feasible; the management of dyslipidemia and hypertension is supported by HIV treatment guidelines and standard practice in HIV care in the Netherlands,” Smit said. “Such an intervention would therefore focus on strengthening implementation of current guidelines.” – by Andy Polhamus
Disclosures: Smit reports receiving grants from the Dutch Ministry of Health, Welfare and Sport during the study, and from Gilead Sciences, Janssen, Merck and ViiV Healthcare outside the submitted work. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Survival rates are improving in general among people living with HIV, but a pattern of comorbidities is emerging, including noncommunicable diseases, which are likely related to persistent immune activation and increased traditional risk factors among people living with HIV. One such comorbidity is CVD. Relative rates of CVD are increased among people living with HIV, and prevention of CVD represents a key challenge facing HIV caregivers today. In an important article, Smit and colleagues have used data from the Dutch ATHENA Cohort to model CVD rates and, importantly, the effects of strategies to reduce such events. In this study, they find that strategies to reduce traditional risks, such as improving lipids and blood pressure as per standard recommendations, may have the greatest impact to prevent CVD events — by 20%. Notably, smoking cessation, though hard to achieve, was predicted to reduce CVD cases by 13%. These effects were additive, and reducing simultaneous risks would be expected to have the greatest effect on CVD prevention. The magnitude of these predicted effects on traditional CVD risks was larger than that of prevention strategies to increase rates of earlier HIV diagnosis and treatment and to avoid use of combination ART associated with increased CVD risk, though these strategies are nonetheless important. This study demonstrates the important need for reducing traditional cardiovascular risk, including management of smoking, hypertension and lipids. Prevention of diabetes is also important and was not addressed in the study.
The REPRIEVE trial, a Randomized Trial to Prevent Vascular Events in HIV, is an NIH sponsored, international, multicenter trial and is the largest study to date to directly address the question of CVD prevention in people living with HIV. This prospective longitudinal trial will test the novel effects of statins on traditional and nontraditional risks in HIV and determine if such a strategy will prevent CVD events in people living with HIV. In the interim, attention to healthy lifestyle to minimize traditional CVD risks should be a goal for all people living with HIV.
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