Cardiovascular Risk & HIV

The risk of cardiovascular disease in people living with HIV has become a recent subject for debate. The questions on the table: Does an increased risk exist independent of general risk factors (diabetes, smoking, cholesterol, family history)? If an increased risk exists, is it related to HIV infection or HIV treatment? If related to HIV treatment, which specific drugs? Is that risk clinically relevant (i.e. enough to take someone off a successful regimen)?

A satellite symposium sponsored by the HIV Forum, (associated with University of California, Berkeley) gave an overview of current knowledge. The panel had an interesting mix: a consumer, a cardiologist, an HIV specialist, and a statistician. A gentleman living with HIV since 1987 led the session with an effective presentation on increasing cardiovascular risk in PLWH regardless of the etiology (age, medications, HIV) and the need to focus on quality of life in the setting of the dramatic improvements in quantity of life since 1987. The potential risks included:
1. Underlying risks of a patient unrelated to HIV
2. Risks related to HIV infection (potentially due to inflammation related to HIV)
3. Risk related to HIV drugs.

The data to date highlighted the contradictory findings from observational studies, some of which showed increased risk related to HIV, some related to specific RVs (PIs, Abacavir for example), while others found no increased risk. Data from the large SMART study found increased risk in patients who stopped their medications and has raised considerable discussion about the potential risk, even early in HIV disease, of ongoing HIV viermia and potential inflammation. In the studies which found increased risk in PLWH, the risk from cigarette smoking was much greater, highlighting the need to address traditional risk factors as we wait for more definitive information on the role of specific ARVs and cardiovascular risk and if changes in treatment are indicated for everyone, for just folks with high baseline cardiovascular risk, or for no one at all.

Currently there have been no clear guidelines in the dropping of Abacavir and selected PIs for first-line preferred regimens because of potential association with higher cardiovascular risk (they were dropped from preferred for other reasons). There has, however, been discussion if HAART should be started earlier to control viremia and potentially decrease cardiovascular risk. The European guidelines more specifically state that providers should-consider earlier initiation for patients with higher cardiovascular risk. Bottom line: HIV probably does increase risk but not as much as some of the more traditional modifiable risk factors (like smoking). Hopefully, in the future the START study results will show whether treatment practices should be changed.

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