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Certain people with HIV may need more help to reduce their risk of cardiovascular disease

Kaiser Permanente study uses novel method to consider role of cardiovascular disease management

The well-established higher risk of cardiovascular disease in people with HIV compared with people without HIV is more pronounced in key subgroups, according to new Kaiser Permanente research published in Clinical Infectious Diseases. These groups include people with HIV and controlled hypertension, those with inadequately treated cholesterol, and those with a history of frequent unhealthy alcohol use.

Michael Silverberg, PhD

The findings suggest people with HIV need assistance with high blood pressure and cholesterol levels to control their risk of a heart attack or stroke, said study lead author Michael Silverberg, PhD, an epidemiologist with the Kaiser Permanente Division of Research.

“We’ve known for a long time that HIV patients have a higher burden of cardiovascular disease than the general population without HIV,” Silverberg said. “We wanted to learn how that risk may differ among subgroups based on lifestyle risk factors.”

The study also identified a concerning result among people with HIV who reported frequent, unhealthy alcohol use: a 2-times higher likelihood of a negative cardiovascular health outcome. “That tells us that drinking has the potential to be especially harmful for patients with HIV,” said senior author Derek Satre, PhD, an adjunct investigator with the Kaiser Permanente Division of Research and professor at the University of California, San Francisco. “Our study population is generally healthy with good viral control and we still found this strong association, so it’s an important finding.”

Frequent, unhealthy alcohol use was defined in the study as drinking 5 or more days in the previous 90 days, with more than 4 drinks in a day for a woman or more than 5 drinks in a day for a man.

The study included 8,285 people with HIV who are members of Kaiser Permanente Northern California (KPNC) and compared them with 170,517 KPNC patients who were similar in age and racial or ethnic background but did not have HIV. In general, people with HIV maintained good control of their HIV disease, with 79% receiving antiretroviral therapy and 74% having undetectable HIV levels.

The information from this study helps clinicians focus on the right aspects of an individual patient’s care to make the greatest impact when we’re talking face to face in the exam room.

–Brad Hare, MD


The research team used a novel method to calculate a disease management index that measured how well and for how long the study participants managed 3 health conditions: high blood pressure, high blood sugar, and high cholesterol, while also considering the role of obesity, smoking, and alcohol use. The researchers then looked at cardiovascular health outcomes, including coronary heart disease and ischemic stroke, comparing people with HIV to demographically similar people without HIV.

The study showed that, overall, people in both groups had excellent blood pressure, cholesterol, and blood sugar control. It also found no increased risk of heart disease and stroke for people with HIV who had their blood sugar and diabetes controlled. However, people with HIV who had hypertension under control still had worse cardiovascular health outcomes as did people with HIV who had out-of-control cholesterol.

“As we see our patients living longer with HIV, we are becoming more and more focused on maintaining their excellent health into old age,” said study co-author Brad Hare, MD, an HIV specialist with The Permanente Medical Group. “That relies heavily on managing their risks for other common health problems such as cardiovascular disease. The information from this study helps clinicians focus on the right aspects of an individual patient’s care to make the greatest impact when we’re talking face to face in the exam room.”

Derek Satre, PhD

Another notable finding of the study was an increased cardiovascular risk even for people with HIV who don’t have lifestyle risk factors such as smoking, obesity, and those who reported no alcohol use. According to the authors, this points to HIV-specific factors that may still be contributing to the higher risk of a stroke or heart attack in some people with HIV.

“Some of the people in our study have been infected with HIV for decades,” Silverberg said. “Even though these patients’ HIV disease is very well controlled, the long-term effects of past immune suppression or inflammation may still be contributing to their higher risk of cardiovascular disease.”

“This highlights that people with HIV, even those with well controlled HIV disease, should remain vigilant about their cardiovascular disease risk, and continue to take steps to maintain a healthy lifestyle,” he added.

Novel disease management tracking

This is one of the first large scale studies to use a relatively new method for assessing how well a condition is managed over time, named the disease management index (DMI). The DMI was developed in part by co-author Andrew E. Williams, PhD, an informaticist and assistant professor at Tufts University School of Medicine.

Silverberg said the DMI could be a useful tool for public health purposes or in health systems that want to evaluate the quality of its management programs for patients with chronic medical conditions. “This is a time-updated measure of quality of care and evaluates how well a condition is managed and for how long,” he said. The DMI methodology is explained in detail in an appendix to the published paper as a resource for others who may want to use it.

The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

Additional co-authors were Tory M. Levine, MPH, Alexandra M. Lea, MPH, Stacy A. Sterling, DrPH, Jennifer O. Lam, PhD, and Stacey E. Alexeeff, PhD, of the Division of Research; Jason A. Flamm, MD, of The Permanente Medical Group; Kendall Bryant, PhD, of the National Institute on Alcohol Abuse and Alcoholism; Matthias Cavassini, MD, of Lausanne University Hospital; Suzanne M. Ingle, Of the University of Bristol; and Amy C. Justice, MD, of Yale University.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.


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