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 CVD, the underlying mechanisms driving this association, and the implications for patient care.

The Rising Incidence of CVD in People with HIV

Historically, CVD was less prevalent in people with HIV (PWH) due to the shorter survival times before the advent of ART. However, as ART has dramatically improved survival rates, the incidence of CVD in PWH has risen significantly. Current data indicates that PWH experience a higher incidence of cardiovascular pathology compared to their HIV-negative counterparts. ¹ The prevalence of cardiac involvement in AIDS patients has been reported to range between 28% and 73%. ²

Underlying Mechanisms: Inflammation and Beyond

The increased risk of CVD in PWH is not simply a consequence of shared risk factors like smoking or hypertension. Instead, it’s driven by a complex interplay of factors, with chronic inflammation playing a central role. Even with effective ART, immune activation persists in many PWH, leading to elevated levels of inflammatory markers such as interleukin-6 (IL-6) and C-reactive protein. ³

Recent research has identified several potential mechanisms contributing to this chronic inflammation:

• Clonal Hematopoiesis: The expansion of certain blood cell clones can contribute to systemic inflammation.
• Trained Immunity: This phenomenon involves an exaggerated immune response to subsequent stimuli, potentially exacerbating inflammation.
• Lipidomics: Alterations in lipid metabolism may also play a role in initiating inflammatory pathways. ³

Specific Cardiac Manifestations

HIV can affect the cardiovascular system in various ways, leading to a range of cardiac complications. These include:

• Atherosclerotic Cardiovascular Disease (ASCVD): Accelerated development of plaque buildup in the arteries.
• Cardiomyopathy: A disease of the heart muscle that can impair its ability to pump blood effectively. ⁴
• Pericardial Disease: Inflammation of the sac surrounding the heart.
• Valvular Heart Disease: Problems with the heart valves.

Diagnosis and Management

Early detection and management of CVD in PWH are crucial. Advances in cardiac imaging modalities and immunology are improving our understanding of the pathogenesis of HIV-associated CVD and enabling more accurate diagnoses. ¹ Management strategies focus on:

• Optimizing ART: Achieving and maintaining viral suppression is paramount.
• Managing Traditional Risk Factors: Controlling blood pressure, cholesterol, and blood sugar.
• Lifestyle Modifications: Encouraging healthy diet, regular exercise, and smoking cessation.
• Targeting Inflammation: Research is ongoing to identify therapies that can specifically reduce inflammation in PWH.

Looking Ahead

The link between HIV and CVD is a growing public health concern. Continued research is essential to unravel the complex mechanisms driving this association and to develop effective prevention and treatment strategies. A proactive approach to cardiovascular risk assessment and management is vital for improving the long-term health and well-being of individuals living with HIV.