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 of HIV-Associated CVD

The precise mechanisms driving the increased risk of CVD in people living with HIV are multifaceted and continue to be investigated. Persistent immune activation, even in individuals on ART, is believed to play a crucial role. Inflammatory markers, such as interleukin-6 (IL-6) and C-reactive protein, remain elevated and are associated with increased mortality. 4

Recent research highlights several potential pathways:

• Clonal Hematopoiesis: The expansion of certain blood cell clones can contribute to chronic inflammation.
• Trained Immunity: Immune cells can develop a “memory” of prior activation, leading to an exaggerated inflammatory response.
• Lipidomics: Alterations in lipid metabolism may contribute to the development of atherosclerosis.

Advances in cardiac imaging modalities and immunology are deepening our understanding of these processes. 2

Types of Cardiovascular Disease Associated with HIV

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

• Cardiomyopathy: Weakening of the heart muscle.
• Coronary Artery Disease: Narrowing of the arteries supplying the heart.
• Heart Failure: The heart’s inability to pump enough blood to meet the body’s needs.
• Atherosclerotic Cardiovascular Disease (ASCVD): A buildup of plaques in the arteries.

Global Impact and Regional Variations

The prevalence of cardiac involvement in individuals with HIV has been reported to range from 28% to 73%. 1 The impact of HIV-associated CVD is particularly significant in regions with high HIV endemicity, such as sub-Saharan Africa. Research is focusing on understanding the specific challenges and nuances of this population.

Future Directions and Research Needs

Despite progress, significant knowledge gaps remain in the field of HIV-associated CVD. Further research is needed to:

• Identify biomarkers for early detection of cardiovascular risk.
• Develop targeted therapies to reduce inflammation and prevent CVD progression.
• Understand the long-term cardiovascular consequences of HIV infection.
• Investigate the specific mechanisms driving CVD in diverse populations.

A recent review emphasizes the need to unravel the hidden link between HIV and cardiomyopathy, providing valuable insights for clinicians and researchers. 3

Conclusion

HIV-associated cardiovascular disease represents a growing public health concern. As individuals with HIV live longer, proactive management of cardiovascular risk factors, coupled with ongoing research, is essential to improve heart health and overall well-being. Continued advancements in our understanding of the complex interplay between HIV, inflammation, and the cardiovascular system will pave the way for more effective prevention and treatment strategies.