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Cardiovascular disease risk assessment in HIV: navigating data-sparse zones
  1. Matthew J Feinstein
  1. Correspondence to Dr Matthew J Feinstein, Division of Cardiovascular Diseases, Department of Medicine and Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N. Lake Shore Drive, Suite 1400, Chicago IL 60611-3008, USA; matthewjfeinstein{at}

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Persons with HIV are surviving longer than ever before due to effective antiretroviral therapy (ART) and are increasingly at risk for chronic, non-communicable diseases.1–3 Data from large cohorts in North America and Europe have demonstrated that HIV-infected persons have roughly 50% greater risks for myocardial infarction (MI) than uninfected persons, as well as greater risks for other cardiovascular diseases such as heart failure and stroke.4 ,5 These elevated risks for MI persist even after accounting for cardiovascular risk factors and ART regimens and are thought to result from HIV-associated inflammation, immune activation and atherosclerosis—even in the setting of successful viral suppression with ART.6

To inform efforts to prevent MI in this emerging at-risk population, several studies have evaluated both MI and atherosclerotic cardiovascular disease (ASCVD, which includes MI and stroke) risk prediction models in the setting of HIV. These studies have generally been fairly small and some have assessed surrogate endpoints. Perhaps the best known of these studies, the Data collection on Adverse Effects of Anti-HIV Drugs (D:A:D) Study, used a European and Australian cohort of patients infected with HIV to derive risk prediction equations incorporating HIV-specific treatment exposures; however, the clinical utility of these equations may be limited due to their incorporation of ART medications no longer commonly used.7 Accordingly, the degree to which HIV-specific and general population cardiovascular risk models—such as the 2013 American College of Cardiology/American Heart Association (ACC/AHA) ASCVD Risk Calculator—may apply in the setting of HIV remains unclear.

In sub-Saharan Africa, which is home to the substantial majority of the global HIV-infected population, cardiovascular risk estimation is particularly complicated due to the relative dearth of mature cohorts evaluating cardiovascular complications of HIV. Although some studies in sub-Saharan Africa HIV cohorts have evaluated the prevalence of ASCVD risk factors and subclinical …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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