Time to Recognize HIV Infection as a Major Cardiovascular Risk Factor

According to statistics from the World Health Organization, ≈36.7 million people are currently living with HIV, and 1.8 million become infected every year. Antiretroviral therapy has largely transformed HIV infection into a chronic disease. As a consequence, it is estimated that by the year 2030, 73% of HIV-infected individuals will be ≥50 years of age, and 78% of individuals living with HIV will have cardiovascular disease (CVD).1 Individuals infected with HIV have a significantly increased risk for a variety of cardiovascular complications, including acute myocardial infarction,2 heart failure with both reduced and preserved ejection fraction,3 sudden cardiac death,4 peripheral arterial disease,5 and stroke.6 In the United States, CVD has become a key contributor to mortality among individuals living with HIV.7 The systematic review of longitudinal studies of CVD in HIV by Shah and colleagues8 in this issue of Circulation includes 80 studies with 793 635 individuals living with HIV and a follow-up of 3.5 million person-years. A random-effects metaanalysis was performed to derive a pooled rate and risk of CVD among people living with HIV and to estimate the burden of CVD and HIV at the national, regional, and global levels. The authors report that the relative risk of CVD in persons living with HIV is 2.16 (95% CI, 1.68–2.77) as compared with uninfected individuals. Over the past 26 years, the global population attributable fraction from CVD in the setting of HIV increased from 0.36% (95% CI, 0.21–0.56) to 0.92% (95% CI, 0.55–1.41), and disability-adjusted life-years increased from 0.74 (95% CI, 0.44–1.16) to 2.57 (95% CI, 1.53–3.92) million. Most of these increases took place in sub-Saharan Africa and the Asia Pacific regions. The authors deserve high praise for the vast scope of their study and the large volume of work involved. Some of their findings confirm previous studies but on a broader scale (eg, the risk of incident CVD being 2-fold higher in HIV and similar to other high-risk groups such as patients with diabetes mellitus).2 Most of the limitations of the study are inherent in this type of research and are unavoidable. First, myocardial infarction and stroke are defined differently across the aggregated studies, and the majority of cases were not clinically adjudicated but were categorized using coding. This lack of standardization of myocardial infarction definition may be particularly problematic in HIV, where approximately half are type 29 (ie, demand related, such as in the setting of sepsis or illicit drug use). Second, in a meta-analysis such as this without patient-level data, the contributions of traditional risk factors (eg, high levels of smoking and the metabolic syndrome) and HIV-specific risk factors (eg, HIV medication, degree of HIV control, level of inflammation) cannot be adjusted for or even ascertained. In addition, the cardiovascular risk of patients infected with HIV is likely distinctly different before © 2018 American Heart Association, Inc.