HIV and Cardiovascular Disease: A Growing Concern

For decades, human immunodeficiency virus (HIV) was primarily understood as an immune deficiency disorder. However, with advancements in antiretroviral therapy (ART) extending the lifespan of individuals living with HIV, a new challenge has emerged: an increased risk of cardiovascular disease (CVD). This article explores the complex relationship between HIV and heart health, examining the underlying mechanisms, current understanding, and future research directions.

The Evolving Landscape of HIV and Heart Disease

Early in the AIDS epidemic, cardiac complications were often a consequence of severe immunodeficiency. However, the nature of HIV-associated cardiovascular disease has shifted with the widespread use of ART. Before ART, HIV-associated cardiomyopathy, linked to profound immune suppression, was a primary concern. 1 Now, with improved viral load suppression and immune restoration, the effects of HIV on the cardiovascular system are more subtle, yet still significant.

Understanding the Pathogenesis

The link between HIV and CVD is multifaceted. While the exact mechanisms are still under investigation, several factors are believed to contribute to the increased risk. Persistent immune activation, even in individuals on ART, plays a crucial role. Inflammatory markers, such as interleukin-6 (IL-6) and C-reactive protein, remain elevated and are associated with increased mortality in people living with HIV. 4

Research suggests that several immunologic mechanisms contribute to chronic inflammation in people with HIV, including clonal hematopoiesis and trained immunity. 4 alterations in lipid metabolism may also play a role. 4

Types of Cardiovascular Disease Associated with HIV

People living with HIV are at increased risk for a range of cardiovascular conditions, including:

• Atherosclerotic Cardiovascular Disease (ASCVD): This includes coronary artery disease, heart attack, and stroke.
• Cardiomyopathy: Weakening of the heart muscle.
• Heart Failure: The heart’s inability to pump enough blood to meet the body’s needs.
• Pulmonary Hypertension: High blood pressure in the arteries of the lungs.

Diagnosis and Monitoring

Advances in cardiac imaging modalities, such as echocardiography and cardiac magnetic resonance imaging (MRI), have improved the ability to detect and assess HIV-associated CVD. 2 Regular cardiovascular screening is recommended for individuals living with HIV, particularly those with other risk factors such as smoking, hypertension, or diabetes.

Future Directions and Research

Despite progress in understanding HIV-associated CVD, significant knowledge gaps remain. Further research is needed to fully elucidate the underlying mechanisms, identify effective prevention strategies, and develop targeted therapies. Studies focusing on populations from high-endemic regions, such as sub-Saharan Africa, are particularly important. 2 3

Ongoing investigations into the molecular mechanisms driving HIV-associated cardiomyopathy are crucial for developing effective interventions. 3

Key Takeaways

• HIV infection is associated with an increased risk of cardiovascular disease.
• The nature of HIV-associated CVD has evolved with the advent of ART.
• Persistent immune activation and inflammation play a key role in the development of CVD in people living with HIV.
• Regular cardiovascular screening is essential for individuals with HIV.
• Further research is needed to improve prevention and treatment strategies.