Hi there. My name is Chris Longenecker. I’m a cardiologist at the University of Washington in Seattle, Washington, USA. I specialize in the care of people living with HIV infection. For many years I’ve run a clinic focused on cardiovascular disease management and prevention of cardiovascular disease for people living with HIV, first in Cleveland, Ohio for many years and now in Seattle.
Q：Dr. Longenecker, as an expert in Cardiology, Global Health, and HIV, could you share some insights into the interrelation of these fields? And what led you to focus on the topic of cardiovascular disease (CVD) risks in women living with HIV (WLWH)?
Dr. Longenecker：Yeah, so I’ve been interested in HIV infection for a long time as a risk factor for cardiovascular disease. And if you want to study HIV as a risk factor for cardiovascular disease, I feel like you should do it primarily where people with HIV live, which is in Sub -Saharan Africa. So hence the connection between HIV, global health and Sub -Saharan African health in particular. And when it comes to women, the vast majority of women living with HIV are living in Sub -Saharan Africa. That’s why a lot of my work is done there.
Q：Based on your recent research, could you explain why the HIV-related cardiovascular disease risk is 1.5 to 2-fold higher for women than for men?
Dr. Longenecker：Yeah, so first of all, there’s two pieces to that. There’s the piece of what is the risk factor for HIV—of HIV compared to not having HIV. And as you say, it’s about one and a half or two -fold increased risk overall. But that HIV-specific risk is actually higher for women. We see, for example, in heart failure, that the risk of heart failure is three -fold higher in women with HIV compared to women without HIV. So again, the magnitude of that HIV -specific risk is higher for women than it is for men.
Q：Could you elaborate on the multifactorial mechanisms of enhanced risk, such as traditional risk factors, metabolic dysregulation, early reproductive aging, and chronic immune activation in WLWH?
Dr. Longenecker：Yeah, it’s very complex. I don’t think we understand entirely. But we know that females have a heightened immune response to the HIV virus itself. And they’re able to control the virus effectively because of that. But it leads to some complications of chronic inflammation and immune activation, such as cardiovascular disease. There may be other things that also contribute to cardiovascular disease, such as metabolic disease as you mentioned. There is evidence that the menopausal transition is when women are particularly at higher risk of cardiovascular disease. And it’s possible that HIV accelerates that reproductive aging. And then you mentioned metabolic disease, so obesity, dysglycemia, or diabetes. We are starting to see that more often nowadays. Whether or not it’s due to antiretroviral therapy is still a measure for debate, but some of it may be related to certain types of antiretroviral therapy, and women in particular seem to have weight gain with certain types of ART. I think that there’s other things to consider, such as the social determinants of health. I think that women experience unique stressors in life, and that may also be contributing to the biological processes that lead to cardiovascular events.
Q：How does the use of antiretroviral therapy (ART) mitigate these CVD risks and what are its potential side-effects that may contribute to metabolic dysregulation and obesity?
Dr. Longenecker：The key thing here is that antiretroviral therapy does way more good than harm. And so we know that ART is important to reduce the risk of having a heart attack or a stroke, or having heart failure, cardiomyopathy. So first and foremost, it’s important to take antiretroviral therapy. Certainly, amongst the various options for antiretroviral therapy, there are some that are associated with higher risk, compared to others, and some that are associated with metabolic risks compared to others. I think the important thing is that it’s always a case-by-case basis. If you have someone who is at high risk of high cholesterol, or already has high cholesterol before they start antiretroviral therapy, then you may want to choose a certain type of antiretroviral therapy that doesn’t cause the cholesterol problems. So I take an individualized approach to making those sorts of decisions.
Q：What are the current prevention strategies for CVD among WLWH, especially those living in under-resourced health systems, and how effective are they?
Dr. Longenecker：This is a really important question. In Sub -Saharan Africa it seems from some of our work and the work of others that the rate of atherosclerotic cardiovascular disease is lower than in high-income countries. We’re talking about myocardial infarction, for example. Also the cholesterol levels of people living in Africa also tend to be lower. So I think treatment of high cholesterol as a risk factor is a relatively lower priority. In contrast, hypertension, or high blood pressure, is a very important risk factor in Sub -Saharan Africa and a major cause of stroke and heart failure. So for people living with HIV in Sub -Saharan Africa, first of all, making sure that if you have high blood pressure, having that appropriately treated is the most important thing to prevent cardiovascular disease.
