Navigating Heart Disease and Diabetes with HIV

People living with HIV are more likely to have heart conditions -- yet they're less likely to be on statins that could improve clinical outcomes and provide a significant reduction of cardiovascular events, such as heart attack and stroke in high-risk patients with peripheral artery disease or diabetes and in patients with a history of heart attack. The main problem is that PLWHAs who are on antiretrovirals (ARVs) can discover serious interactions when they add statins to the mix.

Now, research presented at last month's American Heart Association Scientific Session 2017 reveals that in patients without atherosclerotic cardiovascular disease (ASCVD), HIV-positive status is associated with higher statin use, perhaps due to increased physician awareness for the high risk of cardiovascular disease in HIV-positive patients.

EDGE spoke with Dr. Terry Ferguson, U.S. Cardiovascular Therapeutic Head at Amgen, about what these findings mean for PLWHAs.

EDGE: Why are people with HIV more likely to have heart conditions?

Ferguson: I think there are two fundamental reasons; HIV is immune-mediated, and people with HIV have a lot of inflammation going on, so there's an inflammatory response in the body as consequence of the disease. The challenge with HIV and driving atherosclerotic disease is this underlying inflammatory state. For example, people with rheumatoid arthritis have a higher rate of atherosclerotic disease. If there is inflammation going on, then there can be more atherosclerotic disease.

EDGE: What about diabetes? How does that affect PLWHAs?

Ferguson: I think one thing that happens with diabetes is it causes an inflammatory state, so that if there are other things going such as HIV, then it's like pouring gasoline on the fire because it's making your inflammatory response worse.

EDGE: Why aren't they on statins then?

Ferguson: I think that becomes the interesting thing because one of the challenges in people with HIV who are on ARVs is the interactions with statins. The challenge that arises from that can make people's symptoms worse because of the statins, so there is at least concern in the general population about how you use statins in people taking ARVs for HIV, because there may be problems associated with that. There is a hesitancy there because people first response is 'I need to go to statins,' then they realize, 'Oh, I have HIV, so this has become more complicated."

EDGE: Are there other things you can use besides statins in people with HIV who are taking ARVs?

Ferguson: There are other things besides statins that you can use, they just don't work as well as statins do. Statins are really a fundamental pillar. But one Interesting thing from the poster session presented by Dr. Robert S. Rosenson from Mount Sinai in New York was that they looked at patients with either ASCVD and diabetes, then looked at patients without either. The interesting observation is that in patients with ASCVD or diabetes, HIV-positive status was associated with lower statin use, although that's been getting better over time. And in people without ASCVD there was a higher use of statins among those with HIV compared to those without HIV, which may reflect the growing recognition that people with HIV may be at risk more so for ASCVD, and doctors are recognizing statins as preventative therapy while also recognizing that those with HIV are at risk.

EDGE: How was this info received at the recent Scientific Sessions 2017 in Anaheim?

Ferguson: I think that on one hand, there were a number of presentations here that talked about increased global ASCVD risk in patients with HIV. So, there is growing appreciation that this is a problem in HIV patients, as they are living much longer and seeing opportunities for ASCVD. Now people are certainly aware of the ASCVD risk that goes along with HIV. I think that is really well embedded. And as you look at the challenges and gaps from a prevention standpoint, we are doing pretty well.

Statin usage in people just with HIV and not ASCVD and diabetes is about a third of that in people with HIV, and half among those with diabetes. People get that there is a risk, and are now struggling to say as we're seeing more patients with ASCVD and diabetes that are living longer, what do we do to prevent their risk? There are now new medications and opportunities. You're not going to solve the problem until you recognize there is a problem, so now doctors recognize there's a problem, and are finding opportunities to do this better. So, it's good news.

EDGE: What needs to happen next?

Ferguson: I think that there's a couple of things: first, we really need to understand the risks and limitations of statins in the population who have this disease. We need to explore more aggressive forms of therapy to see what newer generation agents are not going to be able to do in this population. This is an interesting loop of people not with HIV per se, but with underlying inflammatory conditions. Part of the larger population needs to realize that inflammation exists and that it's part and parcel of what's going on with the disease. And they need to understand how some therapies can do things to your system to make it more complicated. We need to understand what's driving the disease, how it can be modified, and now that we have much more powerful tools to manage lipids, how can that play in.

For me, the most important thing is that people are appreciating the atherosclerotic risks that are becoming manifest in HIV patients. You don't solve a problem unless you know about the problem, and people can now appreciate how all we've learned about heart disease is absolutely applicable to the HIV population.