by Carolyn Chu, MD, MSc, AAHIVS, AAHIVM Chief Medical Officer

August 30, 2022

Featured Literature:
Jaschinski N, Greenberg L, Neesgaard B, et al. Recent abacavir use and incident cardiovascular disease in contemporary treated people living with HIV. AIDS. 2022 Aug 24.  doi:10.1097/QAD.0000000000003373. PMID: 36001525.  

This analysis of the multinational RESPOND cohort of over 29,300 PWH aimed to investigate whether an association between CVD and recent abacavir (ABC) use was observed under modern treatment scenarios. Investigators also sought to explore if preferential ABC initiation among PWH with renal impairment impacted CVD association, and whether observations differed across estimated 5-year CKD and CVD risk score strata. A multivariate model incorporated known risk factors (including sex, age, BMI, hypertension, dyslipidemia, diabetes, prior CVD and CKD). Smoking status and cumulative exposure to other ARVs previously associated with CVD risk (e.g., ritonavir-boosted lopinavir, boosted darunavir, and integrase strand transfer inhibitors) were also included. Participants were 74.4% cismen (43.7% of Western European ethnicity) with a median baseline age of 44 years. 12.6% had a history of CVD event prior to baseline. Over 6.16 years median follow-up (up to December 31, 2019), the incidence rate of CVD events was 4.7/1000 PYFU. After adjusting for potential confounders, recent ABC use was associated with a 40% increased CVD rate. Investigators found no interaction between the observed ABC association with CVD and estimated CVD or CKD risk score, suggesting a similar CVD incidence rate for recent ABC exposure among participants at both high and low estimated CVD or CKD risk.

Author’s Commentary:

The question regarding abacavir and cardiovascular risk appears to be an enduring one, and many guidelines have incorporated some acknowledgement of this – indicating that for PWH at elevated CVD risk, other ARVs should be considered. However, the application of this in practice runs into other challenging areas – not the least of which is the prevalence of kidney disease, limited (although growing) data regarding NRTI-sparing combinations for both treatment naïve and treatment experienced PWH, and possible CVD risk associated with protease inhibitors and integrase strand transfer inhibitors. The recently released USPSTF update recommends that clinicians prescribe a statin (moderate-intensity therapy was used in the majority of trials reviewed by the Task Force) for primary prevention of CVD for adults 40-75 years of age who have 1 or more CVD risk factors and estimated 10-year risk of a cardiovascular event of 10% or greater. Findings of this study support continued guidelines-recommended caution regarding abacavir initiation in PWH with elevated CVD risk.  

The author has no conflicts of interest to disclose.

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