Cardiovascular disease in human immunodeficiency virus

With widespread access to high‐quality medical care as in Australia, human immunodeficiency virus (HIV) is now considered a chronic, treatable condition, with a good life expectancy. The use of combined highly active antiretroviral therapy has enabled effective suppression of the virus, but has also been associated with increased cardiac morbidity and mortality. Over representation of traditional cardiac risk factors, such as hyperlipidaemia and diabetes, as well as an increased incidence of ischaemic and non‐ischaemic heart disease is now considered a major concern of treatment with antiretroviral therapy. Therefore, a contemporary management strategy for patients with HIV must include active prevention and treatment of cardiovascular risk. This review will outline the complex interplay between HIV infection, antiretroviral drug regimens and accelerated cardiovascular disease, with a particular focus on screening, prevention and treatment options in a contemporary Australian HIV population.     

Cardiovascular disease risk factors and antiretroviral therapy in an HIV-positive UK population

Aim

Although the benefits of antiretroviral therapy (ART) have been dramatic, studies have started to report a variety of drug‐related side effects and toxicities. We sought to characterize the risk factors for cardiovascular disease present in an HIV‐positive population.

Methods

A total of 394 HIV‐positive ambulant patients attending the Royal Free Hospital, London, were asked to complete a questionnaire. Questions focused on smoking habits and general health.

Results

In total, 34% of patients were aged >40 years, 29% had a family history of heart disease, 3% had diabetes, 14% suffered from raised blood pressure, 20% had a body mass index (BMI)>26 kg/m³, 7% had an alcohol consumption above the recommended UK limit, and 18% had total cholesterol levels >6.3 mmol/L. The rate of smoking observed (45%) was much higher than that observed amongst the general population in the British Health Survey for England (34%). There were significant differences between those receiving and not receiving ART. Those on ART tended to be younger (P<0.0001) and less likely to smoke cigarettes (P=0.06) or have an alcohol consumption above the recommended limit (P=0.08), but were more likely to have diabetes (P=0.05). More patients receiving ART reported, and so perceived themselves to have, raised blood fats (P<0.0001). This was confirmed when considering blood lipid levels, where those on ART had significantly raised total cholesterol levels compared to those not currently receiving ART (P<0.0001).

Conclusion

We have demonstrated an excess of cardiovascular risk factors in this cohort. These issues must be addressed if we wish to maintain the benefit of treating HIV infection.

     

Prevalence of metabolic syndrome in adults in Khanh Hoa, Viet Nam

Background The metabolic syndrome (MS) is characterized by a specific clustering of risk factors, including dyslipidemia, central adiposity, systemic hypertension, insulin resistance, and dysglycemia. It is associated with an increased risk of developing cardiovascular disease (CVD). Accurate data on prevalence and characteristics of MS will facilitate the development of preventive strategies for CVD. Objective To estimate accurately the prevalence of MS among Vietnamese adults with the usual criteria or with the criteria modified for Asian populations. Design and methods We studied a representative, cross-sectional, population-based sample of 856 subjects (mean age 52.82 &#177; 16.36) classified in three age groups from 15-34 years, 35-54 years and ＞ 54 years of age, living in Khanh Hoa Province, Viet Nam. MS was diagnosed according to the criteria defined by the Third Report of the National Cholesterol Education Program Expect Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel Ⅲ) (NCEP-ATP Ⅲ) and by the modified criteria for some Asian populations in which the waist circumference (WC) is considered abnormal if it is ＞ 90 cm for males and ＞ 80 cm for females.Results Using the NCEP-ATP Ⅲ criteria, the prevalence of MS in the studied population was 10.0％ (CI 95 ％:8.1-12.3). It was 2.4 ％ in the 15-34 age group (men 4.5％ and women 1.2％),5.2％ (men 6.3％,women 4.5％ ) in 35-54 age group and 15.8％ (men 9.7％, women 21.7％) in over 54 age group, respectively. And it was more common in women than in men (11.7％ vs 8.0％, P ＜0.001). Using 2001 population census data of the whole province over 15 years (695 218 habitants) we estimated that about 35 193 people suffered from the MS.The WC was the least common feature of MS (2.1％ for men and in 6.1％ for women).Overall,45.2 ％ of the studied population had one feature of MS, 23.1％ had two features, 8.2％ had three features, 1.6％ had four features, and 0.2％ had all five features. No feature of MS was identified in 21.7％.Using the modified criteria,the prevalence of MS in the studied population was 15.7％. It was 4.0％ in the 15-34 age group, 12.5％ in the 35-54 age group and 21.5％ in the＞54 age group. Prevalence of modified WC feature was 10.9％ for men and 23.6％ for women.Conclusions MS is more accurately identified among Vietnamese adults using the modified criterion of the WC for some Asian populations. Its prevalence is similar to that in the developed countries. ( J Geriatr Cardiol 2004;1(2) :95-100.)     

高效抗逆转录病毒治疗对人类免疫缺陷病毒感染患者骨密度的影响

目的 评价高效抗逆转录病毒治疗(HAART)对HIV感染患者骨密度(BMD)的影响及其相关因素.方法 收集2007-2008年间50例接受HAART的HIV/MDS患者(治疗组)、12例未用HAART的HIV/AIDS患者(未治疗组)、20例健康对照者(对照组)的临床资料,采用双能X线BMD吸收仪(DEXA)测定BMD以及T值,分别对其数据进行统计分析.结果 治疗组中19例(38.0%)患者发生骨量减少,1例(2.0%)患者发生骨质疏松.对照组中5例(25.0%)发生骨量减少,无骨质疏松者.未治疗组中6例(50.0%)患者发生骨量减少,2例(16.7%)患者发生骨质疏松.未治疗组骨量减少/骨质疏松发生率较对照组显著增高(P=0.02).HIV/AIDS组(包括未治疗组和治疗组)的股骨、股骨颈、大粗隆的BMD[(0.97±0.14)、(0.91±0.13)、(0.76 4-0.12)g/cm2]明显低于对照组[(1.04±0.12)、(0.98±0.14)、(0.84±0.11)g/cm2,P<0.05];而未治疗组和治疗组的BMD差异无统计学意义.治疗组中,骨量减少/骨质疏松与体重<60 kg(r=0.074,P=0.004)、使用HAART前血浆病毒载量(r=5.103,P=0.021)呈正相关.结论 未接受HAART的HIV/AIDS患者较健康人骨量减少/骨质疏松发生率高.HIV/MDS患者BMD较健康人低,接受HAART和未接受HAART治疗的HIV/AIDS患者BMD相当.接受HAART患者中,体重<60 kg、治疗前HIV RNA是发生骨量减少/骨质疏松的危险因素.     

Strong impact of highly active antiretroviral therapy on survival in patients with human immunodeficiency virus-associated Hodgkin's disease

Hodgkin's disease (HD) is the most common non-acquired immunodeficiency syndrome (AIDS)-defining malignancy in human immunodeficiency virus (HIV)-infected patients. We analysed the outcome of patients with HIV-associated HD (HIV-HD) with respect to the use and efficacy of highly active antiretroviral therapy (HAART) and other prognostic factors. To evaluate the effects of several variables on overall survival (OS), Kaplan-Meier statistics and extended Cox regression analysis were performed. Response to HAART was used as a time-dependent variable and was defined as an increase of >0.1 x 10(9) CD4 cells/l and/or at least one viral load <500 copies/ml during the first 2 years following diagnosis of HIV-HD. Fifty-seven patients with HIV-HD diagnosed between 1990 and 2002 were included in the study. In the Cox model, the only factors independently associated with OS were HAART response [relative hazard (RH) 0.19; 95% confidence interval (CI) 0.06-0.60], complete remission (RH 0.30, 95% CI 0.13-0.72), and age 相似文献   

联合抗反转录病毒治疗对艾滋病合并恶性肿瘤的影响

目的:探讨联合抗反转录病毒治疗(combination antiretroviral therapy,cART)后艾滋病合并恶性肿瘤的流行趋势及发生风险的变化。方法:在国家艾滋病综合防治信息系统中筛选出2004年1月1日至2018年12月31日的湖北籍人类免疫缺陷病毒(human immunodeficiency virus,HIV)抗体阳性患者,分析其在不同cART阶段的艾滋病合并恶性肿瘤的肿瘤类型。以2013年湖北省或全国普通人群恶性肿瘤的发病率为对照,分析艾滋病人群中的恶性肿瘤标准化发病率(standardized incidence ratios,SIR),并比较2004年至2013年与2014年至2018年不同cART阶段艾滋病合并恶性肿瘤的发生风险变化。统计学方法采用χ²检验。结果:共纳入22994例艾滋病患者,其中艾滋病合并恶性肿瘤323例。艾滋病相关恶性肿瘤(acquired immunodeficiency syndrome-defining cancers,ADC)以非霍奇金淋巴瘤(non-Hodgkin lymphoma,NHL)和宫颈癌常见,非艾滋病相关恶性肿瘤(non-acquired immunodeficiency syndrome-defining cancers,NADC)以肝癌、肺癌常见。与普通人群比较,艾滋病人群的总体恶性肿瘤发生风险并未增加(SIR=1.06,χ²=0.62,P=0.426),但卡波西肉瘤、NHL、霍奇金淋巴瘤、宫颈癌和除鼻咽癌外的头面部癌的发生风险显著升高(SIR=834.09、9.65、13.33、5.22、2.94,χ²=11747.27、625.54、56.65、184.21、13.66,均P<0.01),肺癌、结直肠肛门癌、胃癌和乳腺癌的发生风险显著降低(SIR=0.33、0.36、0.43、0.45,χ²=33.43、12.84、9.01、7.21,均P<0.05)。2014年至2018年宫颈癌、肝癌和结直肠肛门癌的SIR分别为4.06、0.43和0.10,分别低于2004年至2013年的7.42、1.96和0.84,差异均有统计学意义(χ²=5.39、19.52、10.86,均P<0.05)。结论:目前艾滋病合并恶性肿瘤的发病率与普通人群无明显差异,但肿瘤类型存在差异。本地区最常见的恶性肿瘤是NHL和宫颈癌,应注意在该类肿瘤患者中筛查HIV,有助于开展综合治疗以提高疗效。     

Metabolic syndrome in HIV-infected middle-aged women on antiretroviral therapy: prevalence and associated factors

Objectives

To determine the prevalence of metabolic syndrome (MetS) and its associated factors in a group of HIV-infected middle-aged women.

Gender differences in factors associated with adherence to antiretroviral therapy

OBJECTIVE: To identify gender differences in social and behavioral factors associated with antiretroviral adherence. DESIGN: Prospective cohort study. SETTING: Methadone maintenance program. PARTICIPANTS: One hundred thirteen HIV-seropositive current or former opioid users. MEASUREMENTS AND MAIN RESULTS: Participants were surveyed at baseline about social and behavioral characteristics and at monthly research visits about drug and alcohol use and medication side effects. Electronic monitors (MEMS) were used to measure antiretroviral adherence. Median adherence among women was 27% lower than among men (46% vs. 73%; P < .05). In gender-stratified multivariate models, factors associated with worse adherence in men included not belonging to an HIV support group (P < .0001), crack/cocaine use (P < .005), and medication side effects (P = .01). Among women, alcohol use (P = .005), heroin use (P < .05), and significant medication side effects (P < .005) were independently associated with worse adherence. In a model including both men and women, worse adherence was associated with lack of long-term housing (P < .005), not belonging to any HIV support groups (P < .0005), crack or cocaine use (P < .01), and medication side effects (P < .0005). In addition, worse adherence was associated with the interaction between female gender and alcohol use (P < or = .05). CONCLUSIONS: In this cohort of current and former opioid users, gender-stratified analysis demonstrated that different social and behavioral factors are associated with adherence in men and women. Among both men and women, worse adherence was associated with lack of long-term housing, not belonging to an HIV support group, crack/cocaine use, and medication side effects. Among women only, alcohol use was associated with worse adherence.     

Metabolic syndrome: a closer look at the growing epidemic and its associated pathologies

Obesity is reaching epidemic proportions with recent worldwide figures estimated at 1.4 billion and rising year‐on‐year. Obesity affects all socioeconomic backgrounds and ethnicities and is a pre‐requisite for metabolic syndrome. Metabolic syndrome is a clustering of risk factors, such as central obesity, insulin resistance, dyslipidaemia and hypertension that together culminate in the increased risk of type 2 diabetes mellitus and cardiovascular disease. As these conditions are among the leading causes of deaths worldwide and metabolic syndrome increases the risk of type 2 diabetes mellitus fivefold and cardiovascular disease threefold, it is of critical importance that a precise definition is agreed upon by all interested parties. Also of particular interest is the relationship between metabolic syndrome and cancer. Metabolic syndrome has been associated with a plethora of cancers including breast, pancreatic, colon and liver cancer. Furthermore, each individual risk factor for metabolic syndrome has also an association with cancer. Our review collates internationally generated information on metabolic syndrome, its many definitions and its associations with life‐threatening conditions including type 2 diabetes mellitus, cardiovascular disease and cancer, providing a foundation for future advancements on this topic.     

Metabolic syndrome in African Americans: implications for preventing coronary heart disease

The metabolic syndrome represents a specific clustering of cardiovascular risk factors in the same individual (abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, insulin resistance, a prothrombotic state, and a proinflammatory state). Almost 50 million American adults (about one in four) have the metabolic syndrome, which puts them at increased risk for the development of diabetes mellitus and cardiovascular disease. African Americans, especially African-American women, have a high prevalence of the metabolic syndrome. This is attributable mainly to the disproportionate occurrence in African Americans of elevated blood pressure, obesity, and diabetes. Management of the metabolic syndrome consists primarily of modification or reversal of the root causes (overweight/obesity and physical inactivity) and therapy to reduce or control the risk factors. Although all components of the metabolic syndrome should be addressed, optimal control of atherogenic dyslipidemia and elevated blood pressure may reduce cardiovascular risk by more than 80%.     

Adherence to antiretroviral therapy: factors independently associated with reported difficulty taking antiretroviral therapy in a national sample of HIV-positive Australians

Objectives

Given the importance of adherence to combination antiretroviral therapy (cART) for the reduced morbidity and improved mortality of people living with HIV infection (PLWH), we set out to determine which of a number of previously investigated personal, socioeconomic, treatment‐related and disease‐related factors were independently associated with self‐reported difficulty taking antiretroviral therapy (ART) in an Australian sample of PLWH.

Methods

Using data from a national cross‐sectional survey of 1106 PLWH, we conducted bivariate and multivariable analyses to assess the association of over 70 previously investigated factors with self‐reported difficulty taking ART. Factors that maintained an association with reported difficulty taking ART at the level of α=0.05 in the multivariable logistic regression analysis were considered to be independently associated with reported difficulty taking ART.

Results

A total of 867 (78.4%) survey respondents were taking antiretroviral medication at the time of completing the HIV Futures 6 survey. Overall, 39.1% of these respondents reported difficulty taking ART. Factors found to be independently associated with reported difficulty taking ART included younger age, alcohol and party drug use, poor or fair self‐reported health, diagnosis of a mental health condition, living in a regional centre, taking more than one ART dose per day, experiencing physical adverse events or health service discrimination, certain types of ART regimen and specific attitudes towards ART and HIV.

Conclusions

Thirteen previously investigated factors were found to be independently associated with reported difficulty taking ART, reaffirming the dynamic nature of adherence behaviour and the ongoing importance of addressing adherence behaviour in the clinical management of PLWH.     

Metabolic syndrome: collapsing under its own weight?

Invited counterview to article by Cameron AJ, Zimmet PZ, Shaw JE, Alberti KGMM. The metabolic syndrome: in need of a global mission statement. Diabet Med 2009; 26 : 306–309     

Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review

AIMS: Adherence to highly active antiretroviral therapy (HAART) is a key predictor of survival for human immunodeficiency virus (HIV)-infected people. Suboptimal adherence among marginalized populations such as HIV-positive drug users could be associated with clinical failure and the emergence of viral resistance. OBJECTIVE: To conduct a systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU) and identify factors associated with non-adherence to HIV treatment. DATA SOURCES: Seven electronic databases were searched for peer-reviewed papers published in English, French, Spanish or Portuguese, from 1996 to 2007. STUDY SELECTION AND DATA ABSTRACTION: Studies were excluded if they presented only qualitative data, were reviews themselves or assessed other populations without disaggregating data on DU. Findings on adherence were extracted and summarized. DATA SYNTHESIS: Forty-one studies were considered, which studied a total of 15 194 patients, the majority of whom were HIV-positive DU (n = 11 628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e. Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patents receiving care in structured settings (e.g. directly observed therapy) and/or drug addiction treatment (especially substitution therapy). CONCLUSION: While lower than other populations-especially among users of stimulants, incarcerated DU and patients with psychiatric comorbidities-adherence to HAART among HIV-positive DU can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support.     

Metabolic syndrome and estimates of cardiovascular disease in cirrhotic patients

OBJECTIVE: The expected survival rate in patients with liver cirrhosis has increased in recent years, putting them into a clinical scenario in which cardiovascular disease and metabolic syndrome could be common causes of morbidity and mortality. This study aimed to analyze the prevalence of metabolic syndrome and other risk factors and estimate the risk of cardiovascular disease in patients with liver cirrhosis. METHODS: We conducted a cross‐sectional study assessing the patients’ lifestyle, and their anthropometric and biochemical data. Their metabolic syndrome and estimates of their risk of cardiovascular disease were calculated, comparing patients with and without liver cirrhosis. RESULTS: The study included 355 patients (99 cirrhotic and 256 non‐cirrhotic patients). There were no differences between them in the prevalence of metabolic syndrome (39.4%vs 45.7%, P = 0.340). In patients with liver cirrhosis, the mean values of criteria for metabolic syndrome increased as the model end‐stage liver disease (MELD) score increased (P = 0.01). The mean value of a 10‐year risk for cardiovascular disease was lower in the cirrhotic patients (3.4 ± 3.5%vs 5.8 ± 6.8%, P = 0.001). CONCLUSION: Metabolic syndrome is prevalent in patients with liver cirrhosis, but their estimated risk for cardiovascular disease is lower than in non‐cirrhotics. The MELD score is a good marker for assessing the severity of the metabolic syndrome in this group.