Veterans With HIV Are Diagnosed With Heart Failure Earlier Than Those Without

By: Mary Anne Dunkin

PROVIDENCE, RI — Individuals infected with HIV have up to twice the risk of cardiovascular disease and an increased risk of heart failure (HF) compared to those without HIV.¹

A new study led by the Providence VAMC indicates that veterans with HIV who develop HF are also likely to do so sooner. Additionally, veterans with HIV are diagnosed with HF at a significantly younger age compared with veterans without HIV.²

Researchers found that veterans with HIV were on average 14 years younger than veterans without HIV at the time of HF diagnosis in an analysis of 1,420,894 veterans without HIV and 5,093 veterans with HIV who had first received a diagnosis of HF in the VA healthcare system between 2000 and 2018.

“Among those without HIV, the median age for heart failure diagnosis was 72, while the median for those with HIV was 58,” explained lead author Sebhat Erqou, MD, PhD, of the VA Providence Medical Center. This finding was considered a reflection of the variance in the underlying population age structure of veterans with and without HIV due to difference in age distribution between the two populations.

When statistical weights were applied—calculated for each one‐year strata of veterans with HIV from 2000 to 2018—to veterans without HIV to standardize the age structure (a direct standardization approach), the age gap lessened, but persisted. “The median age of diagnosis was no longer 72 years—it was 63, so the gap narrowed,” Erqou told U.S. Medicine. “It became five years. It is still a big difference for age at onset of new heart failure.” These findings suggest that people with HIV have a younger onset of HF compared with individuals not living with HIV.

HIV patients might have a higher “biological age” compared to their chronological age, hence the premature onset of certain diseases in this population, Erqou said. This is possibly due to factors related to chronic HIV infection, antiretroviral therapy (ART), lifestyle factors and comorbidities (e.g., smoking and depression) that are more common in those living with HIV.

The age differences were broadly consistent across important subgroups including inpatient and outpatient HF diagnosis, HF with preserved and reduced left ventricular ejection fraction (LVEF), VA and community diagnosis, men and women, during the time period between 2009 and 2018, and 2000 to 2008, and smokers and nonsmokers. “We adjusted for several risk factors and predicted what the age would be after accounting for differences in smoking, racial composition, comorbidity, etc., between the two groups, and there still was a similar difference in age,” he added.

Earlier Onset

In analyses restricted to individuals with HIV, the researchers found that the median age at HF diagnosis was lower in those with lower CD4 count, higher viral load or those not on ART, suggesting that immunological and inflammatory changes related to HIV may play a role in earlier onset of disease. Whether more aggressive treatment to control the disease process would delay HF is not known.

Additional findings about HIV-infected and non-infected veterans included:

• The prevalence of diabetes mellitus and myocardial infarction was similar between veterans with and without HIV with HF.
• The prevalence of hypertension and chronic kidney disease was higher among veterans with HIV.
• The prevalence of depression, smoking, homelessness, alcohol and substance abuse was significantly higher among veterans with HIV.
• The median LVEF (47%) and brain natriuretic peptide (BNP) (≈200 pg/mL) was comparable between veterans with and without HIV with HF.

A primary strength of the study is that it used the largest data available to date to directly address the question of earlier age of onset of HV in HIV, the authors wrote. Also, various subgroup analyses indicate the robustness of the findings, suggesting HF to be among the age‐related diseases that develop early in those living with HIV. Limitations of the study are that the results are mostly applicable to men, given the predominantly male composition of the veterans. Further it is not clear whether the findings are generalizable to patients with HIV outside of the U.S. or the VA, because risk factors and HIV treatment tend to differ by location. The first diagnosis of HF was based only on VA data, without being supplemented by Medicare and Medicaid data, which might miss first cases of HF diagnoses in non-VA settings. Further studies are needed to make the findings more generalizable.

While the findings are concerning, they also mean people are living longer with HIV, Erqou noted, adding that “a few decades ago, the goal of treatment for people with HIV was to keep them from getting infections that could prove fatal. They are now living longer. Their life expectancy is getting closer to the general population and with that they are getting more heart disease. The way physicians care for people with chronic HIV infection is also changing.

“Change means focusing on prevention, taking care of their cholesterol, exercising and not smoking and so on, because heart disease and stroke are now becoming important factors impacting their life expectancy. That is the implication of the study, and the consistency is striking. We need to think about prevention earlier on.”

1. Feinstein MJ, Steverson AB, Ning H, et al. Adjudicated Heart Failure in HIV‐Infected and Uninfected Men and Women. J. Am. Heart Assoc. Published November 1, 2018. doi.org/10.1161/JAHA.118.009985
2. Erqou S, Jiang L, Choudhary G, et al. Age at Diagnosis of Heart Failure in United States Veterans With and Without HIV Infection. J. Am. Heart Assoc. Published May 5, 2021. doi.org/10.1161/JAHA.120.018983