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The association of cardiovascular risk
factors and disease in people living with HIV
in the UK: a retrospective matched cohort study
Higher CVD Risk With HIV, Especially in People Younger Than 40
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IAS 2021, 11th IAS Conference on HIV Science, July 18-21, 2021
Mark Mascolini
People with HIV infection carry a higher risk of composite cardiovascular disease (CVD) than matched controls without HIV, and this risk is higher with HIV in people under 40 years old, according to results of an exacting 20-year retrospective study in the UK [1]. University of Birmingham researchers and colleagues from other centers estimated that HIV-positive adults have about a 50% higher risk of composite CVD than the general population. But people younger than 40 have a doubled risk of CVD compared with their HIV-negative age group, as well as a higher risk of all-cause mortality.
The University of Birmingham's Tiffany Gooden and colleagues noted that many analyses of CVD risk in people with HIV date from a decade ago, had small samples not representing the general population, and had no HIV-negative control group. Many of these studies took place in the United States, where the healthcare system differs from several other high-income countries, which provide free healthcare.
To overcome these limitations and update estimates of CVD risk with HIV, Gooden and coworkers turned to The Health Improvement Network (THIN) database, which enrolls patients in more than 800 general practices and represents the whole UK population. The analysis included everyone 18 or older with HIV matched to up to 4 HIV-negative people by age (within 1 year), sex, and general practice. The study period stretched from January 2000 to January 2020.
The primary endpoint was risk of composite CVD, which included stroke, peripheral vascular disease, ischemic heart disease, myocardial infarction (MI), and heart failure. The researchers also evaluated risk of each of these CVD components and considered an array of CVD risk factors: hypertension, type 2 diabetes, chronic kidney disease, lipid-lowering drugs (a stand-in for abnormal lipids), and atrial fibrillation (irregular fast heartbeat). Cox proportional hazard regression models to explore CVD risk with versus without HIV controlled for age at index date, index year, sex, ethnicity, economic deprivation, body mass index, and smoking status. Risk analyses for individual conditions, such as stroke, excluded people already diagnosed with that condition.
The research team amassed 9233 people with HIV matched to 35,721 HIV-negative controls. The groups were similar in age (average about 41 years), proportion of women (34.5%), body mass index (about 25% overweight and 15% obese), smoking status (about one quarter current smokers and half never smokers), and comorbidities. The HIV group included a smaller proportion of whites (37% vs 45%), a higher proportion of blacks (23% vs 4%), and worse economic status by deprivation index.
Overall, people with HIV had about a 50% higher risk of composite CVD (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.30 to 1.83). HIV-positive people younger than 40 had a doubled risk of composite CVD compared with HIV-negative people that age (HR 2.01, 95% CI 1.29 to 3.13) and a 6-fold higher risk of all-cause mortality (HR 6.09, 95% CI 4.36 to 8.51). HIV-positive people 40 or older also had a higher composite CVD risk than HIV-negative controls that age.
For the entire study population (regardless of age), people with HIV ran a higher risk of two CVD components, stroke (HR 1.49, 95% CI 1.11 to 2) and ischemic heart disease (HR 1.59, 95% CI 1.25 to 2.02). The HIV group also had a trend toward higher MI risk (HR 1.39, 95% CI 0.99 to 1.95).
Compared with HIV-negative women, those with HIV had more than a doubled risk of MI (HR 2.67, 95% CI 1.02 to 6.95) and ischemic heart disease (HR 2.34, 95% CI 1.17 to 4.71). Compared with HIV-negative men, those with HIV had about a 50% higher risk of stroke (HR 1.55, 95% CI 1.11 to 2.15) and ischemic heart disease (HR 1.47, 95% CI 1.14 to 1.91).
The higher composite CVD risk for the whole HIV group held true both for men and women, for people younger than 40 and 40 or older, for current or ex-smokers and never smokers, and for those in index years 2000-2009 and 2010-2019.
Gooden and coworkers believe their findings endorse guidelines recommending routine screening for CVD in people with HIV. They stressed, though, that HIV guidelines often recommend CVD screening in people older than 40, whereas they found a distinctly higher risk of CVD in HIV-positive people under 40 than in HIV-negative people that age. The investigators underlined the need for an HIV-specific CVD risk assessment tool for everyone with HIV.
The researchers added that their study is limited by inability to control for antiretroviral therapy and CD4 count, and by wide confidence intervals in some secondary analyses. But they saw strengths in gathering an HIV+/HIV- matched population-based cohort, a 20-year study period, and the ability to estimate risk of composite cardiovascular disease.
Reference
1. Gooden TE, Gardner M, Wang J, et al. The association of cardiovascular risk factors and disease in people living with HIV in the UK: a retrospective matched cohort study. IAS 2021, 11th IAS Conference on HIV Science, July 18-21, 2021. Abstract OAA0103.
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The association of cardiovascular risk factors and disease in people living with HIV in the UK: a retrospective matched cohort study
IAS 2021 July 18-22
Presenter: Tiffany Gooden
Authors: T. Gooden * (1 ), M. Gardner (1 ), J. Wang (1 ), K. Jolly (1 ), D.A Lane (1,2), LA Benjamin (3,4,5), H.C Mwandumba (6,7), V. Kandoole (6,8,9), S. Manaseki-Holland (1 ), G.YH Lip (1,2), K. Nirantharakumar (1 ), GN. Thomas (1 ).
we found an increased risk for CVD despite controlling for common risk factors which included age, sex, ethnicity, deprivation, BMI, smoking status and comorbidities at baseline including hypertension, type 1 and 2 diabetes, lipid-lowering drug use and chronic kidney disease. The second point can be taken from our sub-group analysis where we see that irrespective of age, sex and smoking status, people with HIV have a heightened risk of CVD.....typical assessment tools rely on these characteristics to determine CVD risk, but given our analysis, it is likely these tools do not accurately detect CVD risk in people living with HIV
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