Excess Risk for Atherosclerotic Cardiovascular Outcomes Among US Adults With HIV in the Current Era

Abstract

Background In the 2000s, adults with HIV had a higher risk for atherosclerotic cardiovascular disease (ASCVD) compared with those without HIV. There is uncertainty if this excess risk still exists in the United States given changes in antiretroviral therapies and increased statin use. Methods and Results We compared the risk for ASCVD events between US adults aged ≥19 years with and without HIV who had commercial or supplemental Medicare health insurance between January 1, 2011, and December 31, 2016. Beneficiaries with HIV (n=82 426) were frequency matched 1:4 on age, sex, and calendar year to those without HIV (n=329 704). Beneficiaries with and without HIV were followed up through December 31, 2016, for ASCVD events, including myocardial infarction, stroke, and lower extremity artery disease hospitalizations. Most beneficiaries were aged <55 years (79%) and men (84%). Over a median follow-up of 1.6 years (maximum, 6 years), there were 3287 ASCVD events, 2190 myocardial infarctions, 891 strokes, and 322 lower extremity artery disease events. The rate per 1000 person-years among beneficiaries with and without HIV was 5.53 and 3.49 for ASCVD, respectively, 3.58 and 2.34 for myocardial infarction, respectively, 1.49 and 0.94 for stroke, respectively, and 0.65 and 0.31 for lower extremity artery disease hospitalizations, respectively. The multivariable-adjusted hazard ratio (95% CI) for ASCVD, myocardial infarction, stroke, and lower extremity artery disease hospitalizations comparing beneficiaries with versus without HIV was 1.29 (1.18-1.40), 1.26 (1.13-1.39), 1.30 (1.11-1.52), and 1.46 (1.11-1.92), respectively. Conclusions Adults with HIV in the United States continue to have a higher ASCVD risk compared with their counterparts without HIV.

Keywords: HIV; myocardial infarction; peripheral artery disease; stroke.

Figure 1

Cumulative incidence of atherosclerotic cardiovascular disease, myocardial infarction, stroke, and lower extremity artery disease hospitalizations among beneficiaries with HIV and age‐, sex‐, and calendar year–matched beneficiaries without HIV in the MarketScan database. Atherosclerotic cardiovascular disease includes myocardial infarction, stroke, and lower extremity artery disease hospitalizations.

Figure 2

Hazard ratios (HRs) for atherosclerotic cardiovascular disease (ASCVD), myocardial infarction (MI), stroke, and lower extremity artery disease (LEAD) hospitalizations among beneficiaries with vs without HIV across subgroups defined by beneficiary characteristics. Squares represent mean point estimates for HRs, and horizontal bars represent 95% CIs. HRs and 95% CIs are shown in Table S4. HRs include adjustment for age, sex, calendar year, geographic region of residence, history of coronary heart disease (CHD), diabetes mellitus, stroke, peripheral artery disease, heart failure, chronic kidney disease, liver disease, cardiologist care, any hospitalization, depression, tobacco use, polypharmacy, antihypertensive medication use, statin use and statin intensity, and nonstatin lipid‐lowering medication use. *P<0.05 comparing HRs for outcome events associated with HIV infection across subgroups. All other P values comparing HRs for outcome events associated with HIV infection across subgroups defined by beneficiary characteristics were ≥0.05. ^†Data not shown given the small number of events. Specifically, there were 6 LEAD hospitalizations during follow‐up among beneficiaries in 2016.