Although historic scale-up of antiretroviral therapy (ART) is keeping people living with HIV (PLHIV) alive, 1 in 10 of them succumb to cardiovascular diseases (CVDs). “The good news is that survival of PLHIV has improved, but CVD is increasingly becoming one of the important causes of morbidity and mortality” said Dr K Naik of Lokmanya Tilak Municipal Medical College (LTMMC), Mumbai. Dr Naik was speaking at the 6th National Conference of AIDS Society of India (ASICON 2013).
Dr Naik’s data shows that 35.7% of PLHIV had a cardiac involvement. In his study, 5.9% of PLHIV were also having diabetes, 2.6% had a previous history of ischaemic heart disease (IHD) and 4.6% had hypertension. 29.8% of PLHIV in the study had abnormal echocardiogram (ECG). Among those PLHIV who had abnormal ECG, 93.3% had at least one significant finding in their 2D Echo said Dr Naik. 23.2% of PLHIV in the study had low left ventricular ejection fraction (LVEF). In another study done in Madurai Medical College in 2011, 48% of PLHIV had abnormal ECG.
Speaking about pericardial effusion among PLHIV Dr Naik said that 11.9% of them had pericardial effusion. Among those PLHIV who had pericardial effusion, 3.4% had thin rim, 1.9% had mild, 5.9% had moderate and 0.7% had severe pericardial effusion. Pericardial effusion was also associated with tuberculosis (TB).
In Dr Naik’s study, 26.4% of PLHIV had diastolic dysfunction and 15.9% had pulmonary artery hypertension (PAH). Among those with PAH, 9.9% had mild, 5.3% had moderate and 0.7% had severe grade.
Dr Naik found that those with abnormal 2D Echo had a lower average CD4 count (149) than CD4 count of those with normal 2D Echo (which was 333).
Dr Dilip Mathai, a stalwart physician, who is also the Vice President of AIDS Society of India and was earlier with Christian Medical College (CMC) Vellore, said to Citizen News Service (CNS) that data of Dr Naik is alarming as mean age of PLHIV was 38.3 and 35.7% of them were showing cardiac involvement. Dr Mathai advised that perhaps it will make more sense for healthcare providers to look for cardiac involvement in younger PLHIV as well.
Dr Hiten Thaker from UK said that there are modifiable and non-modifiable risk factors for CVDs among PLHIVs (most of which remain same for HIV negative people too). Studies show that PLHIV have higher burden of modifiable CVD risk factors. Higher rates of diabetes, hypertension, tobacco use, dyslipidaemia or abnormal lipids, among PLHIV, further increase the risk of CVDs.
In another study (DAD) which was a collection of 11 prospective cohorts from Europe, Australia and the USA with 30,000 participants, it was found antiretroviral (ARV) drug Abacavir increased myocardial infarction (MI) risk by 94% and Dideoxyinosine (ddl) drug increased the MI risk by 53%. Dr Thaker cautioned that drug choices may influence impact and CVD risk.
Dr Thaker strongly recommended lifestyle modifications especially for PLHIV to lower their individual risk for CVDs such as quitting tobacco use, improving nutrition (increasing vegetables, fruits, whole grains and high fibre food, avoid saturated fats and sugars, decreasing sodium intake, etc), and exercising, among others. Controlling blood pressure and managing diabetes are also important healthy choices for PLHIV that reduce CVD risks.
Quitting tobacco use has shown positive impacts by decreasing CVD risk, said Dr Thaker.
A ‘bad cholesterol’ called LDL levels are higher in PLHIV on ART which ups their risk to hypertension, CVDs, among others. Some studies show there is at least 20% more CHD risk for PLHIV due to high LDL (intermediate risk is 10-19%). Also it is very important for PLHIV to keep their viral load low as it results in lesser inflammation in body.
Dr BB Rewari from National AIDS Control Organization (NACO) had presented a study earlier at 11th ICAAP documented by Citizen News Service (CNS). Dr Rewari had said that “cardiac abnormalities are directly responsible for deaths in 11% children living with HIV.” In a study 100 children living with HIV (below the age of 18 years) with no pre-existing congenital or acquired heart disease were enrolled. ECG and other CVD related tests were done. 4% were found to have palpitation, 1 patient had a breathing difficulty, 2% had grade-II systolic murmur, 1% had muffled heart sound and 3% had cardiomegaly (among which 1 child had pericardial effusion and 2 had dilated cardiomyopathy), said Dr Rewari.
Echocardiographic abnormalities were found in 50% children living with HIV and 37% had left-ventricular dysfunction. “There is increasing incidence of cardiac involvement in children after initiating ART but is less documented” said Dr Rewari. In another study done on adult PLHIV in India, 20-22% had diluted cardiomyopathy and pericardial effusion.
COLLABORATIVE ACTIVITIES? Best time for collaborative activities was certainly 'yesterday'. The need is indeed compelling to find effective collaborative activities between programmes addressing CVDs and HIV.
Expanding access to antiretroviral therapy (ART) and HIV care services have helped people living with HIV (PLHIV) to lead a better quality of life but closing our eyes to other non-HIV healthcare needs such as CVDs will reverse health benefits. (CNS)