The Impact of HIV and Antiretroviral Therapy on Cardiovascular Diseases in Sub-Saharan Africa

Abstract

Increased access to antiretroviral therapy (ART) for people living with HIV (PLWH) has substantially improved survival in countries with a high prevalence of HIV. With better survival, PLWH in sub-Saharan Africa now live to ages that are associated with an increased risk of non-communicable disease (NCDs). Cardiovascular diseases (CVD) constitute a large proportion of these NCDs partly due to the effects of HIV and antiretroviral treatment (ART) on metabolic risk factors like body mass index, blood pressure, cholesterol and diabetes. This dissertation uses quantitative methods to explore the impact of HIV and ART on cardiovascular diseases and its risk factors among PLWH from sub-Saharan Africa in the ART era. The methods used are guided by the causal relationships that HIV and ART have with metabolic risk factors and cardiovascular diseases, and the dissertation constitutes of three papers that analyze different parts of these relationships. In paper one, I used data from public facilities in Tanzania to assess the incidence and risk factors of overweight and obesity after initiation of ART. In the second paper, I conducted a meta-analysis to quantify the effect of treated HIV on cardiovascular diseases that is independent of metabolic risk factors, and the percent of excess risk of CVD that mediated through metabolic risk factors. In the third paper, I used individual-level data on metabolic risk-factors, population-level data on HIV prevalence and ART coverage, estimates on the impact of HIV on metabolic risk factors and on CVD, and a CVD risk prediction model to quantify the proportion of PLWH in Uganda with raised blood pressure and high total cholesterol and each individual’s 10-year risk of CVD (stroke and coronary heart disease). Together, these three papers, provide insights on how HIV and ART affect CVD risk and on the progression of PLWH in sub-Saharan Africa to HIV-CVD comorbid states. I show that clinical and public health interventions for controlling metabolic risk factors cannot adequately prevent cardiovascular diseases among PLWH, and that despite the growing burden of these diseases in PLWH, the burden is much bigger among HIV-uninfected individuals due to larger population figures.