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Co-Morbidities of HIV & Cardiovascular Disease

Both the virus and its treatments contribute to higher rates of cardiovascular disease for patients

In the early stages of the HIV/AIDS epidemic, being diagnosed with HIV meant one thing for the patient: certain death. There weren't any drugs available to treat an HIV infection, and so patients' immune systems failed, leaving them vulnerable to many different types of opportunistic infections and cancers (which eventually caused their deaths).

The development of protease inhibitors in 1995 offered HIV patients a lifeline. When these drugs were combined with other drugs, HIV replication could be suppressed, and patients' immune systems could rebound. Today, standard treatment for any patient diagnosed with HIV consists of a combination of at least three drugs in what is often called a highly active antiretroviral therapy cocktail (a HAART cocktail).

The HAART cocktail has completely changed the clinical picture for anyone who is diagnosed with HIV. Early in the epidemic, if you were diagnosed with HIV at age 25, you probably died before the age of 35. Today, however, if you're diagnosed at age 25, but begin HAART treatment in a timely fashion, you can expect to live well into your 70's. In other words, HIV infected persons can live a "normal" lifespan.

HIV Sets the Stage for Heart Disease
In the midst of this good news for HIV infected individuals, there is also some bad news.

"Contemporary evidence suggests that HIV creates a pro-inflammatory, pro-atherogenic state in the individuals who are infected," stated Michael V. Relf, RN, PhD, AACRN, ACNS-BC, CNE, co-author of an article titled "Cardiovascular Disease and HIV: Pathophysiology, Treatment Considerations, and Nursing Implications," which was published in Critical Care Nurse, the journal of the American Association of Critical-Care Nurses (AACN). "This places them at higher risk for atherosclerotic heart disease, myocardial infarction, cardiomyopathy and congestive heart failure."

HAART is Bad for Hearts
As if that alone wasn't bad enough, researchers who have been studying the long-term effects of HAART therapy on HIV-infected patients have concluded that their increase in cardiovascular risk is two-fold: HAART therapy creates its own metabolic problems for the patients who depend upon it.

Protease inhibitors induce hyperlipidemia and insulin resistance, which plays an important role in atherogenesis and the progression of coronary artery disease.1 This means that the risk factors associated with cardiovascular disease, such as diabetes, dyslipidemia, and hypertension, are more prevalent in persons living with HIV than in the general population-and, due to the HIV, the aging process in general is more severe. Today, the leading cause of death among persons living with HIV is cardiovascular disease.2

In addition, people with the HIV infection begin to experience cardiovascular complications and symptoms at an earlier age than people in the general population. "Normally, cardiovascular problems start affecting people in their 50s," Relf said. "HIV-infected patients will begin having symptoms in their 40s, or even as early as their 30s."

Complicated Co-Morbidities
When a patient presents with both HIV and cardiovascular disease symptoms, "Their care is very complicated," Relf asserted. "There's so much that goes into the management and care of one patient. Also, because HIV regimens are so complex and varied, there are almost no generalities to be made."

The HIV drug combinations that make up a HAART cocktail are as unique and varied as the individuals infected with the virus. "There are several dozen drug combinations that might work to achieve viral suppression," Relf noted. "One patient might have to try 6 or 7 different drug combinations before finding the unique recipe that will work for them."

Because treating the HIV is such a delicate balancing act, Relf noted, "Once a patient is having success with a HAART regimen-if they are able to be adherent to it and have achieved viral suppression-you probably want to leave that in place."

That means when an HIV-infected person begins showing signs of severe atherosclerosis, for example, the healthcare provider who initiates treatment will have to carefully monitor how his chosen cardiovascular drug is interacting with the patient's HAART regimen.

"There are probably going to be drug-drug interactions," Relf commented. "It's almost impossible to avoid. The healthcare provider who encounters a patient with these co-morbidities will have to work with an interdisciplinary team to minimize symptoms, drug interactions and negative side effects. Clinicians must realize at the outset that they will probably not be able to eliminate all of the patient's problems."

The Takeaway for Nurses
Despite all of the education-based prevention efforts in schools and healthcare providers' offices, there continue to be approximately 50,000 new HIV infections each year in the U.S. And currently, it is estimated that only 1 out of 8 HIV-infected persons knows their status. "That means, in the U.S today, there are more than 100,000 people living with the HIV virus who don't know their status," Relf commented.

The statistics are also rather grim for patients who are aware of their condition and are trying to manage it. "Only 30% of patients receiving HAART therapy (3 out of 10) have achieved viral suppression."

Relf believes that nurses, who comprise the largest (and most trusted) group of healthcare professionals in the U.S. today, have a duty to build and maintain a very solid clinical knowledge base with respect to HIV/AIDS.

"Regardless of the setting a nurse practices in, he or she has probably already come into contact with someone who is living with HIV," Relf asserted. "You will encounter these patients in the emergency department, in surgery, on the labor and delivery floor, at the psychiatrist's office - and as a nurse, you need to be prepared to help them."

Because nurses are such a large group, and they often report spending the most time with patients, "They can make a real difference in the lives of people living with HIV," Relf said. "They can provide prevention and treatment education, make referrals for specialized care, or engage in advocacy efforts. Nurses can be on the front lines, steering this crisis in a better direction."

Anne Collins is on staff. Contact her at: acollins@advanceweb.com.


References

1. Hsue P, Giri K, Erickson S, et al. Clinical features of acute coronary syndromes in patients with human immunodeficiency virus infection. Circulation. 2004;109(3):316-319.

2. Fedele F, Bruno N, Mancone M. Cardiovascular risk factors and HIV disease. AIDS Rev. 2011;13(2):119-129.


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