People living with HIV appear to develop cardiovascular disease (CVD) and hypertension earlier than those without HIV, and they seem to be increasingly likely to develop chronic kidney disease (CKD), according to a new study.

On average, CVD and hypertension occurred about 2 years earlier in people living with HIV. And from about age 40 on, CKD burden increased more quickly, the researchers report.

“The earlier development of CVD and hypertension in people living with HIV than in those without HIV indicates premature aging, whereas the increased burden of CKD indicates accelerated aging,” lead study author Tiffany E. Gooden, MPH, and her colleagues at the Institute of Applied Health Research of the University of Birmingham, UK, write in an article published in HIV Medicine.

To compare disease progression over time in adults living with HIV and in those without HIV, Gooden and her colleagues analyzed electronic records data from the IQVIA national UK primary care database between January 2000 and January 2020.

For each of the four conditions they investigated — CVD, hypertension, type 2 diabetes mellitus (T2DM), and CKD — the researchers created a group. Each group included around 9000 participant pairs that consisted of one person living with HIV and one without HIV.

The authors used age at diagnosis to investigate premature aging, and they used age at exit date to investigate acceleration. Participants who had any of the outcomes at baseline were excluded from those specific outcomes.

Propensity scoring was used to match the participants, and linear regression was used to determine age differences at diagnosis between people with HIV and those without HIV for each outcome, as well as prevalence trends for age at exit date.

They reported the following findings:

• The people living with HIV experienced earlier onset of CVD (54.5 vs 56.8) and earlier onset of hypertension (49.7 vs 51.4), both of which indicate premature aging.

• No difference was found for T2DM (53.4 vs 52.6) or CKD (57.6 vs 58.1).

• Starting from age 40, CKD burden increased over time, indicating accelerated aging, but hypertension and T2DM burden did not increase.

“Premature aging identified by CVD and hypertension diagnoses implies that either underlying mechanisms of HIV infection and/or exposure to ART are important drivers,” the authors write. “However, compared with other risk factors such as smoking, the aging effect of HIV/ART is not as large; for instance, smoking has been found to result in coronary atherosclerosis 10 years earlier than never smoking.

“As the life expectancy of people living with HIV continues to increase, future research should prioritize ascertaining how to alleviate any increased aging in people living with HIV to ensure optimal wellbeing and quality of life as they age,” they add.

Clinical Implications and Next Questions

“We may need to consider screening people living with HIV for cardiovascular disease and hypertension at younger ages than current guidelines, which are generally geared toward people without HIV, recommend,” Kara S. McGee, PA-C, DMS, MSPH, physician assistant specializing in infectious diseases at Duke Health in Durham, North Carolina, told Medscape Medical News.

Dr Kara McGee

“It is important that we educate people living with HIV that they may develop comorbidities earlier than people without HIV,” she said in an email. “And we need to ensure that they have access to appropriate health promotion and interventions to prevent, diagnose, and treat conditions like cardiovascular disease and hypertension.”

She added, “As the authors point out, a weakness of the study is that they did not have data about participants’ antiretroviral treatment, CD4 cell count, and viral load, so they were unable to explore the impact of these factors.”

Dr Joachim Voss

Joachim G. Voss, PhD, RN, ACRN, FAAN, professor and director of the PhD program in nursing at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland, Ohio, said that because people with HIV are now living into their seventh and eighth decades, they need to learn about their risk for comorbidities.

“We usually try to show accelerated aging through cell-based, epigenetic, or neurocognitive studies,” he explained in an email. “This study focused on patient outcomes and used a matched cohort study approach, which cleverly accounted for many confounding variables.

“Access to the British database and having 20 years of data are major strengths of the study,” he added.

Dr Matthew Freiberg

Matthew S. Freiberg, MD, professor of medicine and chair in cardiology at Vanderbilt University Medical Center in Nashville, Tennessee, called this an important area of research and a difficult concept to study.

“Whether people with HIV truly experience an accelerated process is open for debate,” he said in an email. “While this study reports that this is the case, others do not.

“This study reinforces the concept that people with HIV have increased risk for certain non-AIDS diseases,” he added. “Understanding this is very important, independent of whether it happens earlier.”

Dr David Wohl

In a phone interview, David A. Wohl, MD, professor of medicine in the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, said that “a big question” among experts in the field is why people who are living with HIV are at greater risk for age-related problems.

“Traditional risk factors for these conditions are more common in people living with HIV,” he said. “And biological mechanisms such as chronic inflammation, which may be higher in people living with HIV, have also been implicated.”

Whether this represents accelerated aging or premature aging is not certain, he noted.

“Although the differences are statistically significant because the authors studied many people, cardiovascular disease and hypertension onset were only slightly earlier,” he said. “And they found no earlier onset for diabetes or for chronic kidney disease.

“We should be clear that this is not a US population,” he said. “Healthcare access in the United States is not as easy as it is in the UK’s National Health System. Most data that compare US and European populations show that people in the United States have a much harder time. They’re not as healthy, they don’t do as well, and they don’t live as long.

“The burden will increase as the population ages, and the healthcare community is not prepared for that,” Wohl cautioned.

Information regarding funding for the study was not provided. The authors, McGee, Voss, Wohl, and Freiberg have disclosed no relevant financial relationships. The study contributed to Gooden’s PhD thesis.

HIV Med. Published online August 7, 2022. Full text

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