According to new research published today in the Journal of the American Heart Association, an open access, peer-reviewed journal of the American Heart Association, people with HIV have a significantly higher risk of having a heart attack as they age if they also have untreated hepatitis C virus, even if their HIV is treated.
The lifetime of HIV-positive people has drastically risen since the development of antiretroviral medicines in the late 1990s.
However, studies have shown that even with therapy, people with HIV still have a heart disease risk that is at least 50% higher than that of people without HIV. This recent study looked at whether those who have both hepatitis C and HIV are more likely to get heart attacks.
“HIV and hepatitis C coinfection occurs because they share a transmission route both viruses may be transmitted through blood-to-blood contact,” said Keri N. Althoff, Ph.D., M.P.H., senior author of the study and an associate professor in the department of epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore.
“Due in part to the inflammation from the chronic immune activation of two viral infections, we hypothesized that people with HIV and hepatitis C would have a higher risk of heart attack as they aged compared to those with HIV alone.”
23 361 HIV-positive individuals who started antiretroviral therapy between 2000 and 2017 were included in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) study. Of these, 17% were female and 49% were non-Hispanic white.
HIV and hepatitis C coinfection occurs because they share a transmission route both viruses may be transmitted through blood-to-blood contact. Due in part to the inflammation from the chronic immune activation of two viral infections, we hypothesized that people with HIV and hepatitis C would have a higher risk of heart attack as they aged compared to those with HIV alone.
Keri N. Althoff
When participants entered in the NA-ACCORD trial, individuals ranged in age from 40 to 79 (median age of 45 years). 4,677 people in the study, or 1 in 5, also tested positive for hepatitis C. The researchers evaluated the occurrence of a heart attack between the HIV-only and HIV-hepatitis C co-infected groups overall and by each decade of age throughout the course of a median follow-up of roughly 4 years.
The analysis found:
- Heart attacks increased by 30% in patients with HIV alone and by 85% in people with HIV plus hepatitis C who were becoming older by a decade at a time.
- Participants who also had established risk factors for heart disease, such as high blood pressure (more than three times), smoking (90%) and Type 2 diabetes (46%), were at an increased chance of having a heart attack.
- Additionally, participants with certain HIV-related characteristics, such as low CD4 immune cell counts (200 cells/mm3, signifying increased immunological dysfunction), and those who took protease inhibitors had a higher risk of heart attack (40%) and 45%, respectively (one type of antiretroviral therapy linked to metabolic conditions).
“People who are living with HIV or hepatitis C should ask their doctor about treatment options for the viruses and other ways to reduce their cardiovascular disease risk,” said lead study author Raynell Lang, M.D., M.Sc., an assistant professor in the department of medicine and community health sciences at the University of Calgary in Alberta, Canada.
“Several mechanisms may be involved in the increased heart attack risk among co-infected patients. One contributing factor may be the inflammation associated with having two chronic viral infections,” Lang said.
“There also may be differences in risk factors for cardiovascular disease and non-medical factors that influence health among people with HIV and hepatitis C that plays a role in the increased risk.”
Characteristics, Prevention, and Management of Cardiovascular Disease in People Living with HIV, an American Heart Association scientific statement published in June 2019, states that over 75% of HIV-positive individuals are older than 45.
“Even with effective HIV viral suppression, inflammation and immune dysregulation appear to increase the risk for heart attack, stroke and heart failure.”
The statement urged additional study into the prevention, causes, and treatments of cardiovascular disease in HIV-positive individuals.
“Our findings suggest that HIV and hepatitis C co-infections need more research, which may inform future treatment guidelines and standards of care,” Althoff said.
The study is constrained by the lack of data on additional risk factors for heart attacks, such as nutrition, exercise, or a family history of chronic illnesses. Results from this study of HIV-positive patients receiving care in North America might not apply to HIV patients in other parts of the world.
In addition, the study period included time prior to the availability of more advanced hepatitis C treatments.
“Because effective and well-tolerated hepatitis C therapy was not available during several years of our study period, we were unable to evaluate the association of treated hepatitis C infection on cardiovascular risk among people with HIV. This will be an important question to answer in future studies,” Lang said.
