Adults with HIV, depression at elevated risk for MI

Chris Longenecker, MD

In 2016, patients with HIV should expect to live long and healthy lives on antiretroviral treatment. Yet, CVD — including acute MI — is an increasing cause of morbidity and mortality in the HIV-infected population in the United States because the population is aging and because there appears to be an increased risk compared with uninfected individuals. Depression and other psychiatric comorbidities such as anxiety disorders are known risk factors for CV events and are common in HIV/AIDS. Plus, they are potentially modifiable with low-tech treatments such as exercise and generic drugs. This study should prompt more patient-centered implementation research to figure out how to integrate mental health interventions into primary prevention strategies in HIV/AIDS clinics worldwide.  

Prior studies from the VACS group on risk for acute MI in patients with HIV have been confirmed in other non-VA cohorts with similar HRs. I suspect these results would be similar in other male HIV-infected cohorts; however, women comprised less than 5% of this cohort. More study is needed to understand the CV risks of co-morbid depression and anxiety in HIV-positive women. We also need more studies from sub-Saharan Africa, where the vast majority of HIV-positive persons live, and where CAD is more prevalent than people realize.  

Primary HIV providers are often infectious disease specialists who are asked to manage not only the patient's HIV, but also all their other primary care needs. These patients are complex with multimorbidity and polypharmacy. Clinicians may not have time to optimally manage depression. It is important that mental health care specialists are integrated into HIV clinics to assist with management. Although some clinics do a great job with this, in other places the resources are thin. The best is a multidisciplinary approach with social workers, dieticians, nurses and physicians all working together to maintain mental and physical health.  

The biggest limitation to observational research like this is the possibility of residual confounding. I think the authors have done a great job addressing this with the available data; however, time-updated co-variates such as CD4+ counts, viral loads and antiretroviral therapy regimens would have been helpful. It is hard to truly understand and fully adjust for the role of alcohol and drug abuse, which are closely linked to depression and are difficult to ascertain from ICD-9 codes.  

Because of the already large pill burden, many of our patients with HIV prefer nonpharmacologic approaches to CVD prevention. Exercise is a low-tech intervention to improve mental health and reduce CVD risk. Providers should consider ways to integrate physical activity into their prescriptions for how to live well with HIV/AIDS.