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Cardiometabolic Considerations

CE / CME

Individualizing ART With Cardiometabolic Considerations

Nurses: 0.75 Nursing contact hour

Pharmacists: 0.75 contact hour (0.075 CEUs)

Physicians: maximum of 0.75 AMA PRA Category 1 Credit™

Released: July 10, 2024

Expiration: July 09, 2025

CME/CE Information

Activity

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Introduction

In this module, Grace A. McComsey, MD discusses integrase strand transfer inhibitors (INSTIs) and cardiometabolic considerations. She provides guidance on assessing weight gain in people living with HIV and discusses the latest data and important considerations when estimating cardiovascular (CV) risk score and the recently updated guidelines on starting a statin.

The key points discussed in this module are illustrated with thumbnails from the accompanying downloadable PowerPoint slideset, which can be found here or downloaded by clicking any of the slide thumbnails in the module alongside the expert commentary.

For those providing patient care, how many people living with HIV do you provide care for in a typical week?

Which of the following should be considered when selecting an initial antiretroviral therapy (ART) regimen for a person living with HIV?

Case Study

The case study for this module illustrates our discussion today about individualizing ART in people with cardiometabolic considerations. A 42-year-old Black cisgender woman was recently diagnosed with HIV and she has come to see you. Her viral load is 37,000 copies/mL and her CD4 cell count is 524 cells/mm3. It is a straightforward case with no comorbidities and no comedications at this point.

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Are all ART options the same if metabolically healthy at HIV diagnosis?

What are the options for this person? We have several ART options, however, should her gender or any other aspect of her case make you think about a specific choice for ART initiation?

HIV Treatment Guideline Recommendations: ART Initiation for Most People Living With HIV

Current HIV treatment guidelines are listed in the Table. Whether you are practicing in the US or in Europe, the guidelines consistently point to INSTIs such as dolutegravir and bictegravir as the best choice when starting an ART regimen, along with a choice of nucleoside reverse transcriptase inhibitors (NRTIs) such as  tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) or abacavir in some cases.1-3

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RESPOND: INSTIs and CV Event Risk

What do we know about INSTIs? Because INSTIs are so important for ART initiation and treatment overall, I think it is very important to learn about every potential adverse event or complication of INSTI therapy.

In this context, the results of the RESPOND study by Neesgard and colleagues were initially worrisome. This study assessed INSTI exposure and CV event risk in approximately 30,000 people living with HIV. They found that CV event risk increased in the first 2 years of INSTI exposure, compared with people who were exposed to non-INSTI regimens. The CVD events were both myocardial infarction and stroke. These complications are very concerning in our patients who are already at high risk for these CV events because of HIV.4

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Swiss HIV Cohort Study Participants: INSTI Impact on CV Events

However, other studies like the Swiss HIV cohort did not show the same results.5 This study evaluated INSTI impact on CV events in more than 5000 people and found that the adjusted CV event risk was similar in people who received INSTIs and people who received non-INSTI regimens. Although it was good to see these results, the conflicting data indicate that we need more studies to definitively know whether INSTIs add to the already increased CV risk in people living with HIV.

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Multivariate Analysis of Weight Gain After ART Start

Weight gain after ART is another important factor to consider. This first study by Paul Sax and colleagues, including myself, was a pooled, multivariate analysis of 8 different randomized control trials of first-line ART.6 We found that weight gain was observed regardless of the ART regimen, with some people gaining a bit, and some people gaining a lot.

INSTIs were associated with more weight gain than non-INSTI regimens, and the middle graph shows that weight gain with bictegravir and dolutegravir was similar.

We also learned that women—and Black women in particular—were at very high risk of weight gain regardless of what regimen they were on. Therefore, it is important to keep weight gain in mind when you are treating women and specifically if they are Black women.

In the clinic, I counsel patients upfront regarding weight gain so they will know what to expect. This is what we did with this case. Even a healthy, young, 42-year-old woman with no other comorbidities, should receive counseling about the risk of weight gain and more importantly, the cardiometabolic consequences of the weight gain and of HIV and its treatment overall.

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HIV-ASSIST

I want to mention the HIV-ASSIST tool.7 This is a free online tool where you can input specific patient data, such as comorbidities, comedications, CD4 cell count, and viral load.

For the woman in our case study it was very simple because she had no comorbidities and was on no medications. This screenshot shows that dolutegravir or bictegravir with TAF/FTC, as well as dolutegravir/lamivudine, were all ranked favorably—any of these drugs would be an excellent first-line regimen for her.

If the patient did have comorbidities such as CV, metabolic concerns, or comedications at baseline, those could be added into the HIV-ASSIST tool and the outcome would be adjusted accordingly.

Taken together, these data suggest that, although we need to be aware of the potential for weight gain (especially in Black women), INSTIs remain a good first-line option. Later we will examine when to use other approaches to address cardiometabolic risk, such as when to recommend a statin (hint: it depends on the person’s CV risk), but the bottom line is that INSTIs can still be recommended for most people living with HIV.

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Which of the following should be considered when selecting an initial ART regimen for a person living with HIV?

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