Significant discrepancies are found between ASCVD guidelines and primary care management of HIV patients in the military health system.
CDR Ryan Maves, MD, FACP, FIDSA
At the 25th Conference on Retroviruses and Opportunistic Infections (CROI), researchers found that improved adherence to the American College of Cardiology/American Heart Association 2013 atherosclerotic cardiovascular disease (ASCVD) management guidelines are critical to minimizing risk of cardiovascular disease in the aging HIV population.
Chronic inflammation associated with even well-controlled HIV infection often results in an increased risk for cardiovascular disease. According to the study, the baseline risk of cardiovascular-related mortality is up to 50% higher for HIV positive patients compared to HIV negative patients.
Indications for statin therapy, however, are similar among infected and uninfected individuals, although current research is being undertaken to determine if it’s sufficient.
“Adherence to guideline based care is critical for the long-term health of our population and has been found to be deficient across multiple previously reported cohort studies,” CDR Ryan Maves, MD, FACP, FIDSA, Naval Medical Center San Diego, and study authors said. “As there are likely multiple systematic causes for poor adherence to guideline based care, we aim to evaluate statin usage within the military is single payer health care system.”
The US Military HIV Natural History Study (NHS, RV168 database) is an ongoing cohort comprised of HIV positive beneficiaries of the Department of Defense healthcare system, collecting data since 1996.
A retrospective cross-sectional analysis was conducted of adherence to guidelines for statin therapy that included subjects aged 21—75 years old whose most recent study visit was between October 2015–September 2016. Of the 1483 subjects with recent visits, 1223 had all inputs for the ASCVD risk estimator.
Researchers used the American College of Cardiology/American Heart Association 2013 ASCVD management guidelines to determine eligibility.
The criteria included known ASCVD like stroke or heart attack, low-density lipoprotein (LDL) cholesterol rates > 190 mg/dL, diabetes with concurrent LDL > 70 mg/dL and age between 40—75, or ASCVD risk calculated to be 7.5% > via the pooled cohorts equation.
Statin use was considered current if any statin was prescribed within in the last 18 months in the system.
The study was comprised of 1066 participants, with selected baseline demographics to include a median age of 47, a patient population predominately male were 95%, white race 40%, African-American race 45%, smokers 16% and diabetic 12%.
Of the 342 (32%) patients that met at least 1 criteria for therapy 188 (55%) were currently prescribed a statin, while among diabetics, 58% of eligible subjects were receiving statin therapy.
The general demographics of individuals receiving statin therapy tended to be older (median age 56 vs 42), white (52% vs 35%) and have a greater chance of being on a protease inhibitor (57% vs 32).
Overall, researchers concluded that significant discrepancies were found between ASCVD guidelines and primary care management of HIV patients in the military health system. Racial disparities were found to persist even in the single-payer network.
Poor adherence to guidelines remain a common issue in the management of patients infected with HIV, despite its wide acceptance. The issue persists aside from easily determinable statin eligibility through free and online ASCVD risk calculators.
It’s necessary to improve adherence to ASCVD guidelines in order to minimize risk of cardiovascular disease in the aging HIV population. As care is becoming more focused on preventative measures, knowledge of these deficits is crucial to the modern practice of infectious disease specialty care.
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