iconstar paper   HIV Articles  
Back grey arrow rt.gif
HIV health system in South Africa is ill-equipped to handle the rising tide of HTN , CVD, Aging, Comorbities - Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa
  Download the PDF here
Feb 2020 - Progress in Cardiovascular Disease
Less attention has been paid to primary prevention of CVD risk among PLWH in SSA
Despite decades of accrued data on increased CVD risk among PLWH in the United States and Europe, similarly compelling data in SSA remain lacking. Data largely derived from cross-sectional studies suggest the following key points: 1) PLWH in SSA are living longer with ART, and are thus increasingly susceptible to CVD risk factors; 2) regional risk factors, such as low nadir CD4 counts, and exposure to air pollution are likely to differentiate risk factors for CVD in the SSA population; 3) PLWH have similar prevalence of CVD risk factors as people without HIV in the region, some evidence of decreased pre-clinical atherosclerosis as measured by cIMT, but appear to be at increased risk of stroke, particularly prior to ART initiation; 4) traditional CVD risk scores do not perform well (using surrogate markers as outcomes) in PLWH in SSA; and 5) there are a multitude of barriers to CVD risk screening and prevention in SSA across the patient, provider and health system levels that require urgent attention. A variety of study designs are needed to respond to the known gaps in the literature and barriers to care, including large prospective cohort studies with outcome estimation, clinical trials, and implementation science evaluations of health systems interventions. These studies must be adequately powered to demonstrate clinical benefits in SSA and are urgently needed to ensure health systems are designed accounting for regional epidemiology and health system capacities. Until the field takes such strides, optimal methods of CVD risk prevention among PLWH in SSA will remain poorly understood and largely unaddressed.
1. PLWH in SSA experience a high incidence of new-onset HTN, particularly in the first 1–2 years after ART initiation.
- efforts are clearly needed to empower patients and providers to translate such guidelines into health benefits.
- Studies on primary prevention interventions in PLWH in the region are lacking, but early efforts will first depend on developing the infrastructure necessary to implement interventions as they are shown to be effective. Currently, there are significant barriers to CVD screening and management across the patient, provider, and health systems levels.
- This data strongly suggests that at least a proportion of the CVD risk attributable to HIV infection can be mitigated with early ART initiation. Notably, the World Health Organization guidelines and most national guidelines now recommend immediate ART initiation for all PLWH. Efforts to execute these guidelines are paramount. Nonetheless, low CD4 T cell nadirs have proved stubbornly persistent in SSA, despite public health prioritization to provide ART for all PLWH.194
2. Women living with HIV (WLWH) in North America and Europe are estimated to have 2 to 4 times higher risk of myocardial infarction, stroke and heart failure as compared to women without HIV infection and approximately equivalent risk compared to men living with HIV (MLWH).
3. Data on arteriosclerosis, which is predictive of future CVD events, but not a marker itself, have generally demonstrated increased arterial stiffness in PLWH than HIV-uninfected comparators. For example, cohort studies from Cameroon and South
-----Africa demonstrated increased pulse-wave velocity among ART-naïve PLWH compared to HIV-uninfected comparators, which was most pronounced in people older than 50 years.
4. In the United States, PLWH appear to have approximately 40–60% increased risk of stroke, which appears greatest in those with advanced HIV disease.78,129,145 Studies from SSA consistently demonstrate that HIV infection is an independent risk factor for stroke
5. there is conflicting evidence for a similar, if not decreased burden of pre-clinical carotid atherosclerosis among PLWH compared to HIV-uninfected counterparts in SSA Compared to the HIV-uninfected population, this translates to a 47% higher risk of smoking among men and 87% higher risk of smoking.
6. HIV health system in SSA is ill-equipped to handle the rising tide of HTN in PLWH with most HIV clinical care services lacking basic equipment such as BP cuffs and sphygmomanometers and front-line healthcare workers with limited basic knowledge about HTN.
- fragmented clinical care for HIV and for HTN, frequent stock outs of BP lowering drugs, as such PLWH with HTN often face severe physical and financial barriers to obtaining treatment for both HIV and HTN.
- In SSA, DM - diabetes- is predicted to increase by 160% by 2030, partly owing to urbanization and unhealthy lifestyles.
- women have higher prevalence of obesity and overweight than men…..Obesity is increasingly common among PLWH in SSA with prevalence rates ranging from 5% in Nigeria55 to 23% in South Africa56 representing a remarkable transformation from the epoch when HIV was defined by “wasting” and “slimming”.
- Africa reported a prevalence for elevated total cholesterol of 26.2% in PLWH compared to 25.5% in the general population, and more than two-fold higher prevalence for elevated low density lipoprotein (LDL)-cholesterol (45.6% vs 21.4%).
Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa

As longevity has increased for people living with HIV (PLWH) in the United States and Europe, there has been a concomitant increase in the prevalence of cardiovascular disease (CVD) risk factors and morbidity in this population. Whereas the availability of HIV antiretroviral therapy has resulted in dramatic increases in life expectancy in sub-Saharan Africa (SSA), where over two thirds of PLWH reside, if and how these trends impact the epidemiology of CVD is less clear. In this review, we describe the current state of the science on how both HIV and its treatment impact CVD risk factors and outcomes among PLWH in sub-Saharan Africa, including regional factors (unique to SSA) likely to differentiate these relationships from the global North. We then outline how current regional guidelines address CVD prevention among PLWH and which clinical and structural interventions are best poised to confront the co-epidemics of HIV and CVD in the region. We conclude with a discussion of key research gaps that need to be addressed to optimally develop an actionable public health response.
Approximately two thirds of the world's population of people living with HIV (PLWH) reside in sub-Saharan Africa (SSA).1 After a lag in resource allocation and implementation of HIV control programs, the continent has seen a meteoric rise in access to HIV treatment over the past decade – with antiretroviral therapy (ART) coverage rates rising from virtually none in 1990s to 62% by 2018.1 This massive public health commitment and implementation has resulted in significantly increased longevity for PLWH. Due to this longevity, the leading causes of mortality among PLWH are now cardiovascular disease (CVD), non-AIDS malignancies, and liver disease.2 In the United States and Europe, there is evidence of heightened risk of myocardial infarction, stroke, heart failure,3,4 and sudden cardiac death5 among PLWH. Globally, the risk of CVD in PLWH is estimated to be 2.5-fold higher than HIV-uninfected persons, contributing to 2.6 million disability-associated life-years (DALYs) annually (a third of which are in SSA).6
In the wake of these epidemiologic shifts among PLWH, there is growing interest in measuring CVD risk factors and outcomes in the sub-Saharan African region has grown; however, most of these data have been limited to risk factor assessments, such as blood pressure (BP) and diabetes and lipids. Despite heterogeneity in unmeasured effects (genetics and environmental risk factors) and relationships between risk factors and outcomes, these data have been used to assess CVD risk, with risk prediction models derived from Western populations, such as the Framingham and Data Collection on Adverse Events of Anti-HIV Drugs (DAD) Risk scores.7,8
Consequently, public health programs for HIV care are at a crucial crossroads, with parallel (or competing) priorities of ensuring all PLWH have access to care, maximizing HIV prevention efforts, and promoting health and quality of life for PLWH. Achieving these goals will require a thorough understanding of CVD epidemiology among PLWH. However, a number of critical questions remain unanswered related to CVD risk among PLWH in SSA:
1) What is the epidemiology of traditional (long-established) CVD risk factors among PLWH on chronic ART?
2) Which regionally relevant risk factors modify CVD risk among PLWH?
3) How do currently available data inform us about how HIV infection directly affects CVD risk in SSA?
4) How well do current regional guidelines account for CVD prevention through routine screening and management?
5) What CVD prevention interventions are most likely to reduce morbidity and mortality in the region?
6) What are the major research gaps that need to be addressed to ensure CVD risk is optimally minimized among PLWH in SSA?
In this systemic review, we aim to address these questions and lay the groundwork for future research and programmatic priorities for this field.
  iconpaperstack View Older Articles   Back to Top   www.natap.org