Assessing Syndemics of Cardiovascular Disease in People with and without HIV - PROJECT SUMMARY/ABSTRACT
Combination antiretroviral therapy (ART) has led to dramatic declines in morbidity and mortality for people with
HIV (PWH). However, as PWH age, the risk of cardiovascular disease (CVD) has increased, with a projected
lifetime burden among PWH of 65% for men and 44% for women. The higher observed risk of CVD in PWH
compared with the general population is a result of the higher prevalence of established CVD risk factors
(smoking, alcohol, dyslipidemia), and direct effects of HIV infection, including immunodeficiency and
inflammation. Recent studies have also implicated integrase strand inhibitors and other ART with increases in
body weight, which may further increase risk of CVD. There are also many understudied social and economic
conditions that may contribute to the high CVD risk in PWH, including disparities in healthcare access and
treatment, social isolation, history of trauma, and HIV stigma. While most studies have considered the impact
of CVD risk factors in isolation, it is well known that many frequently co-occur, such as smoking, alcohol,
obesity and depression. Furthermore, the ways in which social factors exacerbate the effect of biomedical CVD
risk factors among PWH is not well understood. Using a syndemics framework, which is uniquely suited for the
evaluation of the clustering of social and biological conditions in vulnerable populations, we will investigate
reasons for the persistently high risk of CVD among PWH. With the team’s interdisciplinary expertise in HIV,
CVD and syndemics, our study is designed to understand how social, economic and biological factors combine
in PWH, contributing to their high CVD risk. We will leverage comprehensive electronic health record (EHR)
data from Kaiser Permanente (KP) and detailed existing survey and biospecimen from the KP Research Bank
(KPRB). In Aim 1, we will examine synergistic relationships with major adverse cardiovascular events (MACE)
among 29,000 PWH and 1:20 matched people without HIV (PWoH) enrolled in KP from 2000-2021. We will
evaluate clusters of social and biological factors available in EHRs such as mental health, substance use
disorders (SUD), neighborhood deprivation, and insurance benefits. For Aim 2, we will perform a
complementary study within the KPRB to identify synergistic relationships with subclinical CVD among 1,969
PWH (709 with biospecimens) and 1:1 matched PWoH. We will consider additional social factors from surveys
that may impact CVD risk, including discrimination and stigma, social isolation, emotional and practical health
support, and economic factors. Finally, Aim 3 will involve recruitment of 60 PWH from high-risk clusters
identified in Aims 1 and 2 for in-depth qualitative interviews to explore how the syndemic conditions contribute
to the high CVD risk. The interviews will inform a follow-up survey of 350 PWH recruited from the same high-
risk clusters, to confirm syndemic conditions in a larger sample that could be addressed in future CVD
prevention efforts. Integrating quantitative and qualitative data sources, this study has great potential to inform
future comprehensive community- and health system-level interventions to reduce the CVD burden in PWH.
