African Americans taking ART have high incidence of illness associated with risk of cardiovascular disease

Black HIV-positive men and women receiving antiretroviral therapy (ART) have especially high rates of health problems that can increase the long-term risk of cardiovascular disease, investigators from the United States report in the online edition of Clinical Infectious Diseases. Incidence of diabetes mellitus, chronic kidney disease and treated hypertension were all higher among black people compared to other racial groups. In addition, both black and white women had a higher incidence of chronic kidney disease compared to some other groups.

“Sex-race disparities in the occurrence of HTN [hypertension], DM [diabetes mellitus], and CKD [chronic kidney disease] persisted among men and women aging with HIV with access to care,” write the authors. “Our findings are a call to action to: 1) better understand the drivers of these disparities that persist in an environment with equal access to care….and 2) fill gaps in NCD [non-communicable disease] prevention services among adults aging with HIV.”

Thanks to ART, many people with HIV are now living well into old age and illnesses associated with ageing – especially cardiovascular disease – are now an important cause of serious illness and death among ART-treated older people living with HIV. Prevention of disorders that are associated with an increased risk of cardiovascular disease is now a priority of HIV care. However, it is unclear if the risk of these for ageing-related diseases in HIV-positive people differs according to sex and race.

Investigators from North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) therefore designed a study to estimate the incidence before the age of 70 years of key non-HIV-related illness among people who received ART between 2000 and 2013. There were 20 cohorts providing data on diabetes mellitus, 22 cohorts on chronic kidney disease and 16 on treated hypertension.

Overall, around 51,000 people were included in the study; these people were followed for a median of five years and contributed a total of 288,000 person-years of follow-up. The majority (83%) were male, 44% were black and 84% were aged below 50 years. Two-thirds of individuals started ART before 2006.

Half of the participants had a viral load above 400 copies/ml and 44% had a CD4 count below 200 cells/mm³.

Rates of first occurrence of each disease were:

• hypertension = 2.6 per 100 persons-years
• diabetes mellitus = 1.2 per 100 person-years
• chronic kidney disease = 0.6 per 100 person-years.

Median age at diagnosis was between 48 and 51 years.

After taking into account age, risk group and HIV-related factors, the investigators found significant disparities in the risk of these outcomes according to sex and race.

Black race, regardless of sex, was associated with increased rates of hypertension (black women, aIRR = 1.8; 95% CI, 1.6-2.1; black men, aIRR = 1.5; 95% CI, 1.4-1.7).

Compared to non-black men, black women (aIRR = 1.4; 95% CI, 1.2-1.6), black men (aIRR = 2.0; 95% CI, 1.6-2.3) and non-black women (aIRR = 1.4; 95% CI, 1.2-1.7) all had increased incidence of diabetes mellitus.

“Despite blacks comprising only 12% of the US population, blacks have a disproportionate burden of HIV infection,” note the investigators. “The confluence of this burden of HIV infection and the associations of race with NCDs indicates an important clinical and public health issue.”

Women – black and non-black – had significantly higher rates of chronic kidney disease compared to non-black men (aIRR = 1.5; 95% CI, 1.2-19 and 1.5; 95% CI, 1.1-2.0, respectively).

“In the setting of HIV infection, reasons for sex disparities are likely multifactorial, and may include biological differences, and differences in care retention,” suggest the authors. “In light of this, women aging with HIV may require approaches to care that are distinct from those routinely used for men in terms of devising effective prevention and treatment plans for NCDs.”

These race-sex disparities persisted after adjustment for body mass index (BMI).

Cumulative incidence (by age 70) according to race-sex ranged from 51 to 73% for hypertension, 34 to 52% for diabetes mellitus, and 25 to 38% for chronic kidney disease.   

“We found increased rates of HTN, DM, and CKD, especially among HIV-infected black men and women,” conclude the researchers. “Minimizing sex-race health disparities through more proactive preventive care, such as smoking cessation, physical activity, and nutritional assistance programs, will shape the quality of extended life made possible by effective ART in this population engaged in medical care.”