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Integrated Care Asia
HIV and Cardiovascular Diseases in Asia: Can Integrated Healthcare Provide a Better Management Model?

Released: October 12, 2023

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Key Takeaways
  • Many people in China have diabetes and/or hypertension, but a large proportion are either unaware of their condition or their condition is uncontrolled.
  • Research from 2 cohorts in Africa that integrated models of care in persons living with HIV and cardiovascular disease shows these diseases can be managed together with good results.

The message of the day at International AIDS Society (IAS) 2023 was control of cardiovascular risk factors in persons living with HIV. Indeed, several of my colleagues in this program have outlined and commented on key papers regarding management of cardiovascular disease (CVD) in persons living with HIV.

It is well known that CVD is one of the most common causes of non‒AIDS-related death in persons living with HIV. Therefore, screening and controlling risk factors—including hypertension, hyperlipidemia, and hyperglycemia—are crucial prevention measures. In China, HIV diagnosis and treatment guidelines recommend  screening and evaluation of CVD risk factors as a routine for patients in the healthcare system. However, research studies outlining the best methods of clinical implementation are lacking. I’d like to focus this commentary on 2 papers that studied integrated care models for HIV and management of CVD.

RESPOND: Comanagement of HIV With Diabetes and/or Hypertension
The Research Partnership for Control of Chronic Diseases (RESPOND) cohort in Africa reported that less than 20% of those with hypertension or diabetes were aware of their condition and less than 10% were in regular care. On the other hand, 91% of adults in eastern and southern Africa were aware of their HIV infection, 79% were on antiretroviral therapy (ART), and 74% were suppressed virologically. Clinical experts hypothesized that they might be able to achieve better results for metabolic disorders if HIV and CVD care were coordinated.

To me, this is the moment when measures are urgently needed. In China, approximately 25% of the adult population has hypertension, but the hypertension is under control in only 14%. Approximately 15% of adults aged 45 years or older have diabetes but less than half are aware of their condition. Standardized screening can only be provided in tertiary care hospitals. However, most patients living with HIV seek medical treatment in primary health institutions that lack screening guidelines and integrated services.

In the RESPOND cohort, a total of 7028 adults living with HIV, diabetes, and/or hypertension in 32 clinics in Tanzania and Uganda were randomized to either integrated care or standard care. In the integrated care model, patients were seen by 1 physician for care of their diabetes, hypertension, and HIV. At the end of 12 months, a numerically higher percentage of patients in the integrated model had reached the blood pressure goal of <140/90 mm Hg (56.3% vs 47.2% in the standard care model).

Although the difference did not reach statistical significance, I believe it illustrates that care for HIV and care for chronic metabolic diseases can be integrated into 1 comprehensive clinic.

I recognize that there are challenges to integrating CVD prevention in the HIV clinic because infectious disease physicians who are skilled at managing ART and treating opportunistic infections may ignore managing lipids and blood pressure.  In order to improve the screening, adequate specialized training and clear screening procedures need to be provided.

Addressing CVD in Women Living With HIV in Integrated Care Settings by Lifestyle Changes
Women living with HIV are disproportionately impacted by CVD, especially in low- and middle-income countries, so I was interested to see a study from South Africa that addressed lifestyle interventions for women with HIV.

A total of 372 adult women younger than age 50 living with HIV who had been in HIV care for more than 1 year were enrolled either into the intervention arm or standard care control arm. Women in the control arm received a standard-of-care workup and HIV management at primary healthcare clinics, whereas women in the intervention arm were treated at a research clinic and were screened for obesity, hypertension, diabetes, and lipids. They received written lifestyle modification advice that was reinforced at study visits. They were also referred to a dietitian.

After 32 months of follow-up (most of which was during the COVID-19 pandemic), women in the intervention arm were significantly more likely to have a healthy diet, significantly less likely to exercise less than 30 minutes per week, and significantly less likely to have blood glucose >5.6 mmol/L (100 mg/dL). In the intervention group, from baseline to the end of study, the researchers noted significant improvement in HDL cholesterol from abnormal to normal levels. However, both average waist circumference and BMI rose significantly during the study.

The investigators noted 4 new cases of diabetes by the end of study, 1 in the intervention arm and 3 in the control arm. Several barriers were noted that might have interfered with adoption of the prescribed lifestyle changes: financial constraints, work, lack of social support, poor body image, and lack of insight into CVD risk.

In China, two thirds of women living with HIV are older than 40 years of age; perhaps these more intensive methods of intervention might be used to impact some change in our patients.

Integration and CVD Prevention
What do I take away from these studies? To improve health outcomes of persons living with HIV, the focus should be on getting more patients on effective ART; we know that uncontrolled viral replication and and lower CD4+ counts are associated with a greater probability of CV events. On the other hand, we must pay greater attention to CVD prevention and potential negative effects in patients receiving long-term ART. The optimal routine risk screening tools should be explored to identify early and subclinical disease, and a healthy lifestyle should be promoted. Drug intervention such as statins and aspirin should be provided if necessary.

Your Thoughts?
How confident do you feel assessing and managing CVD in your patients? Are you in an integrated care setting? Leave a comment to join the conversation.