Association between HIV infection, antiretroviral therapy, and risk of acute myocardial infarction: a cohort and nested case-control study using Québec's public health insurance database.
ABSTRACT Morbidity associated with cardiovascular disease is increasing in the HIV-infected population. We aimed to study the impact of HIV and of antiretrovirals on acute myocardial infarction (AMI).
We performed a cohort and a nested case-control study using the dataset of the Régie de l'Assurance Maladie du Québec. HIV-positive patients were identified using ICD-9 diagnostic codes and matched to HIV-negative patients. Within the HIV-positive cohort, cases of AMI were identified and matched to HIV-positive patients without AMI. The coprimary outcomes were the risk of AMI associated with HIV exposure in the cohort study and that associated with exposure to antiretrovirals in the case-control study. Data were analysed using Poisson and conditional logistic regression.
About 7053 HIV-positive patients were matched to 27,681 HIV-negative patients. Incidence rates of AMI in the HIV+ cohort was 3.88 95% confidence interval (CI) (3.26 to 4.58) per 1000 patient-years, compared to 2.21 95% CI (1.93 to 2.52) per 1000 patient-years in the HIV cohort. The adjusted incidence ratio of AMI for HIV-infected patients was 2.11 95%CI (1.69 to 2.63). Among HIV+ patients, 125 AMI cases were matched with 1084 HIV+ patients. We found increased odds ratio (95% CI) of AMI associated with any exposure to abacavir 1.79 (1.16 to 2.76), P = 0.02, efavirenz 1.83 (1.21 to 2.76) P = 0.004, lopinavir 1.98 (1.24 to 3.16) P = 0.004, and ritonavir 2.29 (1.48 to 3.54) P < 0.001.
HIV+ individuals were at higher risk of AMI than the general population, and several antiretrovirals were associated with an increased risk of AMI. Results should be interpreted with caution in absence of data on smoking and HIV clinical status.
- [show abstract] [hide abstract]
ABSTRACT: The emergence of chronic disease complications in controlled HIV disease has changed the landscape of HIV clinical care. HIV infection confers an increased cardiovascular disease risk, which is thought to be due to a complex interplay of mechanistic factors. While traditional cardiovascular risk factors likely play a role, recent evidence suggests that HIV-associated inflammation and immune activation are important mediators of cardiovascular risk. It is unclear whether established preventative interventions for the general population are applicable to HIV-infected patients, and the need to translate mechanistic knowledge into HIV-specific clinical interventions represents an important priority. Developing strategies to prevent cardiovascular disease in HIV-infected individuals calls for a multidisciplinary approach and represents an opportunity to exert a major public health impact in an at-risk population.Current HIV/AIDS Reports 06/2013;
- [show abstract] [hide abstract]
ABSTRACT: Background. Individuals infected with human immunodeficiency virus (HIV) are at increased risk for cardiovascular disease (CVD) events compared with uninfected persons. However, little is known about HIV provider practices regarding aspirin (ASA) for primary prevention of CVD.Methods. A cross-sectional study was conducted among patients attending the University of Alabama at Birmingham 1917 HIV Clinic during 2010 to determine the proportion receiving ASA for primary prevention of CVD and identify factors associated with ASA prescription. Ten-year risk for CVD events was calculated for men aged 45-79 and women aged 55-79. The 2009 US Preventive Services Task Force (USPSTF) guidelines were used to determine those qualifying for primary CVD prevention.Results. Among 397 patients who qualified to receive ASA (mean age, 52.2 years, 94% male, 36% African American), only 66 (17%) were prescribed ASA. In multivariable logistic regression analysis, diabetes mellitus (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.28-5.27), hyperlipidemia (OR, 3.42; 95% CI, 1.55-7.56), and current smoking (OR, 1.87; 95% CI, 1.03-3.41) were significantly associated with ASA prescription. Odds of ASA prescription more than doubled for each additional CVD-related comorbidity present among hypertension, diabetes, hyperlipidemia, and smoking (OR, 2.13, 95% CI, 1.51-2.99).Conclusions. In this HIV-infected cohort, fewer than 1 in 5 patients in need received ASA for primary CVD prevention. Escalating likelihood of ASA prescription with increasing CVD-related comorbidity count suggests that providers may be influenced more by co-occurrence of these diagnoses than by USPSTF guidelines. In the absence of HIV-specific guidelines, interventions to improve HIV provider awareness of and adherence to existing general population guidelines on CVD risk reduction are needed.Clinical Infectious Diseases 08/2012; · 9.37 Impact Factor
Article: Nephrology in Africa-not yet uhuru.[show abstract] [hide abstract]
ABSTRACT: Nephrology is a 'Cinderella speciality', a disregarded area of health care, in Africa. Other health issues have relegated the treatment of kidney diseases to a low priority status, and the cost of treating the more common and widespread communicable diseases, financial mismanagement and corruption in many countries has sounded the death knell for expensive therapies such as dialysis. The communicable diseases that have devastated the health systems around Africa are tuberculosis and HIV/AIDS. Until recently, very little information was available on the impact of HIV on acute and chronic dialysis admissions. Patients with acute kidney injury (AKI) in most of Africa are seldom treated because of great distances to travel, lack of expertise, poverty and poor sustainable funding for health matters. An acute peritoneal dialysis (PD) programme has now been initiated in Tanzania but the sustainability of this project will be tested in the future. The International Society of Nephrology (ISN) has developed a training programme for nephrologists from developing countries, which may now be bearing fruit. A report from the sub-Saharan Africa region shows that the numbers of patients on dialysis and those diagnosed with chronic kidney disease (CKD) has increased significantly. Other ISN-sponsored programmes such as Continuing Medical Education activities for physicians and community screening projects have had far-reaching positive effects. Government funding for a dialysis programme is well established in South Africa, but this funding is limited so that the numbers accepted for public dialysis are restricted. Consequently in the Western Cape province of South Africa, a 'category system' has been formulated to attempt to cope with this unacceptable and restrictive ruling.Nature Reviews Nephrology 08/2013; · 7.94 Impact Factor