Cardiovascular disease: Emerging concern for HIV patients

The theme for this year is “Hands Up for #HIV Prevention”. According to the AIDs by the Numbers 2016 report from UNAIDS, 1.1 million people worldwide died of AIDS-related illnesses in 2015. By the end of the same year, an estimated 36.7 million people around the world were living with HIV.

Since 1996, when antiretroviral therapy (ART) became available, people with HIV have been living longer and healthier lives. However, as individuals with HIV age, they are more likely to be diagnosed with chronic illnesses. A growing body of evidence suggests cardiovascular disease in particular is a common occurrence in people over 40 living with HIV. Studies have shown that people living with HIV are 50 to 100 per cent more likely to develop cardiovascular disease (including heart attack and stroke) than individuals without HIV. As people living with HIV (PLWHIV) survive longer, thanks to the massive role out of ART programmes, the HIV population grows older and are developing cardiovascular diseases as new causes of death and disability amongst PLWHIV.

A number of factors combine to put people with HIV at increased risk for cardiovascular disease including HIV infection itself. The virus causes chronic inflammation, which leads to plaque build-up and eventual blockage in the arteries that can cause cardiovascular disease. Additionally, some ART medications used to treat HIV can raise the risk for heart disease by causing insulin resistance which may lead to diabetes; and researchers have revealed that some kinds of HIV drugs such as protease inhibitors are associated with development of high levels of fat in the blood including cholesterol and triglycerides. Both of these may lead to blockage of blood vessel in the various parts of the body.

If left untreated, this heightens the risk of heart, gall bladder, and pancreatitis diseases. Also the rates of some conventional risk factors for cardiovascular disease, such as smoking, are also higher among people with HIV. HIV and cardiovascular disease also share common behavior al risk factors which makes people who develop HIV to also be more likely to develop cardiovascular disease.

HIV itself can further increase the risk of cardiovascular disease. Untreated HIV with its highviral loads has been linked to heart diseases and experts now recommend starting treatment earlier to avoid cardiovascular damage that is caused by active viral reproduction. However, many of the drugs used to treat HIV can also contribute to cardiovascular disease, notably by raising cholesterol and triglyceride levels.

Not only does HIV related inflammation damage the immune and other organ systems, it also accelerates the ageing of blood vessels. The use of ART greatly decreases HIV related inflammation. Indeed, studies have found that people who stop taking ART have a greatly increased risk for heart attacks and stroke. Nevertheless, even in the setting of low, or un-detectable viral load, low-level inflammation triggered by HIV infection may continue to slowly affect organs and blood vessels, but at a much lower level than before. Over the long-term, this inflammation may heighten the risk for cardiovascular disease in HIV-positive people.

The good news is that many steps can be taken to help prevent and manage cardiovascular disease. Decades of research involving HIV-negative and HIV-positive people, have repeatedly shown that lifestyle changes such as diet, exercise and quitting smoking can greatly reduce the risk of cardiovascular disease. When lifestyle changes are not enough, a number of effective medications and other medical approaches are available. It is also important to take cardiovascular risk factors into account when making crucial HIV treatment decisions, such as when to start, or switch treatment and which medications to use.

But the benefits of ART have been shown to greatly outweigh the dangers and researchers warn against stopping HIV drugs to protect the heart. In fact, current research shows that stopping and starting HIV medications can make heart disease worse while putting patients in danger of more serious complications by allowing HIV to reproduce in their bodies.

Regular monitoring of the levels of cholesterol and triglycerides in the blood and other cardiovascular risk factors in the HIV treatment factors and a adoption of prevention, early detection and control can help to control the problem.

Researchers are currently pursuing ways to address the problem of cardiovascular disease among people living with HIV. For example, a current large scale study with several research sites is testing whether statin medications which have been proven safe and effective in reducing cardiovascular disease risk in the general population, can also reduce that risk in patients with HIV.

Scientists also say that newer antiretroviral drugs may be easier on your heart. It is also very important for patients to ask their healthcare provider what they can do to decrease their risk and to find the best HIV medications.

Maintaining a healthy and low cholesterol diet, engaging in adequate physical activity regularly, quitting smoking, screening for cardiovascular risk factors, staying adherent to HIV medications and keeping viral load low/undetectable can reduce cardiovascular diseases.

By Professor Gerald Yonga, Consultant Cardiologist, Aga Khan University Hospital.