Multidisciplinary Collaborative Integrated Management of Increasingly Prominent HIV Complications in the Post-cART Era

L Lin; TS Li


HIV Medicine. 2020;21(11):683-691. 

In This Article

HIV Infection is an Independent Risk Factor for Atherosclerosis

HIV infection is linked to an increased risk of cardiovascular disease (CVD). Traditional cardiovascular risk factors, such as hypertension, dyslipidaemia, diabetes, smoking, obesity and advanced age, may lead to cardiac insufficiency and is more common in PLWH. Among the untreated HIV infections in China, the most common factors are dyslipidaemia and smoking, accounting for 51.7% and 23.7%, respectively. Even without traditional factors, PLWH have a higher risk of CVD than HIV-negative individuals.

HIV may impair cardiac function by directly affecting cardiomyocytes and myofibrils[7] with diastolic dysfunction (DD) being an early indicator of underlying heart disease. In a cross-sectional study of PLWH without CVD symptoms, we observed that PLWH had a higher prevalence of DD vs. HIV-negative controls, most of which were mild or moderate. HIV infection was independently related to DD, while traditional cardiovascular risk factors such as blood pressure, diabetes, and low-density lipoprotein cholesterol were not independently associated with DD. The prevalence of left ventricular systolic dysfunction and increased left ventricular mass (ILVM) in the PLWH group was higher than that of healthy people. The multivariate logistic analysis showed that HIV was a major risk factor for DD and ILVM. Our study results suggest that HIV may trigger mechanisms that lead to cardiac dysfunction.[8]

Studies have shown that heart dysfunction of PLWH is related to cART.[9] Mitochondrial toxicity of ZDV mainly exists in various tissues, including cardiomyocytes. After using ZDV for more than 12 months, the prevalence of cardiac DD increased.[10] Abacavir has been reported to increase the risk of myocardial infarction in patients; however, a 2011 meta-analysis of the Food and Drug Administration showed no statistical association between abacavir and myocardial infarction. The International Antiviral Society–USA and Department of Health and Human Services 2018 guidelines suggest avoiding abacavir (ABC)-based programmes for high CVD risk. Physicians treating patients who are already being administered medication at the risk of developing tip tortuous ventricular tachycardia should be more cautious in choosing efavirenz (EFV) and rilpivirine. The use of the protease inhibitor (PI) is associated with a variety of metabolic abnormalities, including dyslipidaemia, insulin resistance, endothelial dysfunction and CVD. Drug–drug interactions between cART and some statins and hypotensive drugs occur frequently; therefore, drug toxicity and concentration should be fully considered in the combined treatment. To be sure, the benefits of cART in reducing morbidity and mortality far outweigh the increased risk of CVD caused by cART.

Immune activation and inflammation caused by HIV may lead to cardiac dysfunction. PLWH are more likely to develop premature atherosclerosis (AS). Monocytes and monocyte-derived macrophages are cellular hallmarks in AS pathogenesis.[11] The level of neopterin can reflect the activation stage of a mononuclear/macrophage. High circulating levels of soluble tissue factors (TFs) were associated with an increased risk of subclinical AS in PLWH.[12] Mononuclear cells expressing CD16, neopterin, TFs and pulse wave velocity were significantly higher in male PLWH than in healthy controls. Elevated levels of monocyte activation markers were associated with high levels of AS in male PLWH who were receiving cART.[13] Conversely, oestrogen has a significant protective effect on AS; women affected by HIV are much less likely to develop AS than men of the same age. HIV infection itself is a risk factor for peripheral artery disease, independent of traditional cardiovascular risk factors and cART; therefore, treating a potential HIV infection may prevent the progression of AS.[14]

We suggest that CVD risk assessment could be carried out for PLWH, and treatment and intervention should be considered as part of medical care. cART with small influence on lipid metabolism was selected as far as possible. In changing the cART regimen, the relationship between efficacy and adverse reactions should be weighed.