Association of HIV and ART with cardiometabolic traits in sub-Saharan Africa: a systematic review and meta-analysis

Abstract

Background: Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations.

Methods: We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants.

Results: Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, -0.59; 95% CI, -0.86 to -0.31), BMI (SMD, -0.32; 95% CI, -0.45 to -0.18), SBP (SMD, -0.40; 95% CI, -0.55 to -0.25) and DBP (SMD, -0.34; 95% CI, -0.51 to -0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, -0.34; 95% CI, -0.62 to -0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits.

Conclusions: Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

Keywords: ART; HIV; cardiometabolic disease; sub-Saharan Africa.

Figure 1

Study selection

Figure 2

Countries contributing data, by region

Figure 3

Summary of overall estimates from random-effects meta-analyses of associations between HIV and individual cardiometabolic risk factors. SMD, standardized mean difference; CI, confidence interval; BMI, body mass index; TGs, triglycerides; LDL, low-density lipoprotein cholesterol; HDL, high-density lipoprotein cholesterol; SBP, systolic blood pressure; DBP, diastolic blood pressure; HbA1c, glycated haemoglobin

Figure 4

Summary of overall estimates from random-effects meta-analyses of associations between ART and individual cardiometabolic risk factors. SMD, standardized mean difference; CI, confidence interval; BMI, body mass index; TGs, triglycerides; LDL, low-density lipoprotein cholesterol; HDL, high-density lipoprotein cholesterol; SBP, systolic blood pressure; DBP, diastolic blood pressure; HbA1c, glycated haemoglobin; ART, antiretroviral therapy

Figure 5

Participant-level data on the associations of HIV and ART with cardiometabolic traits in the General Population Cohort, adjusted for different amounts of individual-level confounding. Full adjustment includes adjustment for data clustering, ART exposure (when comparing HIV+ and HIV− subgroups), age, sex, BMI, education level and smoking status. SMD, standardized mean difference; CI, confidence interval; BMI, body mass index; TGs, triglycerides; LDL, low-density lipoprotein cholesterol; HDL, high-density lipoprotein cholesterol; SBP, systolic blood pressure; DBP, diastolic blood pressure; HbA1c, glycated haemoglobin; ART, antiretroviral therapy