People with HIV less likely to be prescribed key drugs to reduce cardiovascular risk

Physicians in the United States are less likely to prescribe key recommended medications for the prevention of cardiovascular disease to people with HIV compared to HIV-negative individuals, according to research published in the Journal of the American Heart Association. Prescription rates for aspirin, antiplatelet medications and statins were markedly lower for people with HIV, all of whom presented with symptoms or risk factors for cardiovascular disease.

“To the best of our knowledge, this study is the first to analyze differences in the quality of cardiovascular care between patients with and without HIV using nationally representative data,” comment the investigators. “Our results indicate that US physicians generally underuse guideline-recommended cardiovascular care for high-risk adults and are less likely to prescribe aspirin and statins to HIV-infected adults versus HIV-uninfected adults.”

Cardiovascular disease is now an important cause of serious illness and death in people with HIV. Recent studies suggest that HIV-positive people are up to 100% more likely than their HIV-negative peers to experience a heart attack or stroke. Moreover, the increased risk of cardiovascular disease observed in people with HIV persists even after controlling for traditional risk factors such as smoking, rates of which tend to be higher among the HIV-positive population. The prevention of cardiovascular disease is now an important priority of HIV care. However, little is known about the provision of cardiovascular care to people with HIV, or how this compares to the care provided to HIV-negative people.

US investigators therefore analysed data from representative national sources, comparing the provision of cardiovascular care between HIV-positive and HIV-negative people aged between 40 and 79 years. The individuals presented to doctors with cardiovascular disease or its risk factors.

Data from 1631 visits involving HIV-positive people and 226,862 involving HIV-negative people were analysed. These visits took place between 2006 and 2013.

Outcomes were guideline-recommended use of aspirin, statins, anti-hypertensives, smoking cessation counselling/drug therapy and diet/exercise counselling.

There were significant differences between the HIV-positive and HIV-negative patients. Those with HIV were younger, and also more likely to be male, Hispanic, black and be uninsured or rely on Medicaid. The prevalence of cardiovascular disease and its risk factors (with the exception of smoking) was, however, higher among HIV-negative individuals.

A much lower proportion of HIV-positive people were prescribed aspirin or another antiplatelet medication compared to HIV-negative individuals (5 vs 14%, p = 0.03). Similarly, rates of statin use among people with diabetes, cardiovascular disease or high lipids were markedly lower for people with HIV (23 vs 35% for HIV-negative people, p < 0.01). Overall, people living with HIV were almost 50% less likely to be prescribed a statin or aspirin or another antiplatelet medication (odds ratio 0.51 and 0.53 respectively).

“The differences in aspirin/antiplatelet and statin prescription rates we found – 2 medications that substantially reduce the incidence of adverse cardiovascular events in at-risk populations and are cost-effective – may partly explain differences in cardiovascular event rates between these 2 populations,” suggest the researchers. “While differences in other risk factors, particularly the substantial differences in smoking and HIV-related inflammation, likely play a larger role, the differences in aspirin and statin prescription rates represent a target for quality improvement efforts.”

However, there was no significant difference in the proportion of HIV-positive and HIV-negative people with high blood pressure who were prescribed an anti-hypertensive (53 vs 58%), or in the proportions receiving counselling/drug treatment to stop smoking (19 vs 22%) and counselling about exercise diet (15 vs 17%).

“US physicians generally underused guideline-recommended cardiovascular care for high-risk patients,” conclude the authors. “Professional guidelines, practice-level, or reimbursement-based policy changes that focus on quality of care among patients with HIV will be needed to ameliorate these disparities and reduce HIV-related cardiovascular morbidity and mortality.”