Author + information
- Gerald S. Bloomfield, MD, MPH⁎ ( and )
- Eric J. Velazquez, MD
- ↵⁎Division of Cardiology and Duke Clinical Research Institute, Duke University, 2400 Pratt Street, DUMC Box 3850, Durham, North Carolina 27705
We read with great interest the recent article of Boccara et al. (1) in the Journal calling for a better understanding of HIV and coronary heart disease (CHD). The author's in-depth summary spanned the epidemiology of CHD among people living with HIV, traditional cardiovascular risk factors in this population, pathophysiology, outcomes, and strategies toward prevention and treatment. What was unfortunately absent, however, was any mention of the relationship between HIV and cardiovascular disease where the burden of HIV is greater than anywhere else on the planet—sub-Saharan Africa.
Although CHD is rarely reported among Africans with HIV, a discussion of the relationship of the 2 disorders should not ignore the region of the world where HIV is most rampant, cardiovascular disease risk factors are becoming more prevalent, and the life expectancy of those with HIV is lengthening. Of the 34 million people living with HIV worldwide, 69% (23.5 million) live in sub-Saharan Africa (2). Over the last few decades, it has become clear that chronic cardiovascular diseases and risk factors are on the rise on the African continent (3). For example, a systematic analysis of health examination surveys and epidemiological studies showed that mean systolic blood pressure increased in Africa between 1980 and 2008 (4). A Ugandan study showed that HIV-seropositive patients on combined antiretroviral therapy could achieve a normal life expectancy (5) and the accompanying exposure to risk for developing chronic cardiovascular diseases.
There are a number of other reasons why the experiences in sub-Saharan Africa must be considered in this context, including differences in the common HIV subtypes with known effects on endothelial function (6), the growing burden of traditional cardiovascular risk factors among HIV-seropositive Africans (7,8), and in contrast to the experiences in the West, lower smoking rates in sub-Saharan Africa than most other regions of the world (9). Lastly, although combined antiretroviral therapy is provided by international donors, there is disproportionately little attention and funding for noncommunicable diseases on the continent (10). An untenable disparity exists whereby individuals needing services for HIV and cardiovascular disease in sub-Saharan Africa have free access to the former but little or none to the latter.
The issues surrounding HIV and cardiovascular disease in sub-Saharan Africa are complex but demand urgent attention while the many factors promoting CHD are still nascent. We are in need of a better and broader understanding of HIV and chronic cardiovascular diseases. For this reason, we should apply the apocryphal Sutton law to this paradigm. If we want to understand how HIV affects the cardiovascular system, we should go where the HIV is.
- American College of Cardiology Foundation
- Boccara F.,
- Lang S.,
- Meuleman C.,
- et al.
- ↵(2012) Global Report on the Global AIDS Epidemic (Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland), pp 1–110.
- Report on the Global Tobacco Epidemic
- Nugent R.A.,
- Feigl A.B.