🧬 Introduction
With the success of antiretroviral therapy (ART), people living with HIV (PLWH) now enjoy longer life expectancies than ever before. However, this increased lifespan has brought a new challenge: a significantly higher risk of early cardiovascular disease (CVD).
Research shows that HIV-positive individuals are 1.5 to 2 times more likely to develop heart disease at a younger age compared to HIV-negative individuals. This article explores the underlying causes, scientific findings, and most importantly, how to reduce that risk through prevention and lifestyle changes.
🔬 Why Does HIV Increase Heart Disease Risk?
Cardiovascular disease in HIV patients is multifactorial, meaning it’s influenced by a mix of biological, lifestyle, and treatment-related factors.
1. Chronic Inflammation & Immune Activation
Even with effective ART and undetectable viral load, HIV causes persistent low-grade inflammation in the body. This leads to:
- Damage to blood vessel linings (endothelium)
- Increased plaque formation
- Accelerated atherosclerosis (hardening of arteries)
2. Immune System Dysfunction
HIV affects CD4+ T-cells, weakening the immune system. This dysfunction can:
- Promote autoimmune reactions
- Make the body less effective at repairing vascular damage
3. Side Effects of Antiretroviral Therapy (ART)
Some older or specific ART drugs (especially protease inhibitors and abacavir) are associated with:
- Increased cholesterol and triglyceride levels
- Insulin resistance
- Elevated risk of metabolic syndrome
4. Higher Prevalence of Traditional Risk Factors in PLWH
People living with HIV often have a higher rate of:
- Smoking
- Diabetes
- Obesity
- Sedentary lifestyle
- Co-infections like Hepatitis B/C, which can indirectly impact cardiovascular health
5. HIV-Associated Lipodystrophy
This condition, caused by some ART medications, leads to abnormal fat distribution and metabolic changes, further increasing the risk of heart disease.
🩺 What Does the Research Say?
Several key studies have demonstrated the link between HIV and heart disease:
- The REPRIEVE Trial (NIH, ongoing) is investigating whether statins can prevent heart disease in HIV patients.
- A study published in JAMA Cardiology (2020) found that HIV-positive individuals had a 50–100% higher risk of heart attack than the general population.
- A 2023 report in The Lancet HIV showed increased arterial stiffness and vascular inflammation in young adults with HIV — even those on effective ART.
In short, heart disease now rivals opportunistic infections as a leading cause of morbidity in aging HIV patients.
❤️ Early Warning Signs & Screening
HIV patients often experience “silent” heart disease, where symptoms may not be obvious until major events like a heart attack or stroke occur. Regular screening is essential.
Doctors typically monitor:
- Blood pressure
- LDL/HDL cholesterol
- Blood sugar and insulin levels
- C-reactive protein (CRP) — marker of inflammation
- Carotid intima-media thickness (CIMT) — ultrasound measure of artery wall thickening
🛡️ Prevention Strategies: How to Lower the Risk
Fortunately, many of the risks can be controlled with the right interventions.
✅ 1. Stick to Effective ART
- Modern ART regimens are safer and more heart-friendly than earlier generations.
- Staying virally suppressed reduces inflammation and immune activation.
- If you’re on older ART (e.g., abacavir, lopinavir), talk to your doctor about switching.
✅ 2. Adopt Heart-Healthy Habits
| Lifestyle Change | Why It Helps |
|---|---|
| Quit smoking | Smoking triples heart risk in HIV patients |
| Regular exercise | Improves blood flow, lowers inflammation |
| Balanced diet | Emphasize whole foods, fruits, and omega-3s |
| Limit alcohol | Excess alcohol contributes to hypertension |
| Maintain healthy weight | Reduces blood pressure and blood sugar |
✅ 3. Control Blood Pressure & Cholesterol
- Use statins if needed — they not only lower cholesterol but also have anti-inflammatory benefits in HIV.
- REPRIEVE trial is evaluating long-term statin use in HIV for prevention even in low-risk patients.
✅ 4. Manage Diabetes and Insulin Resistance
- Monitor A1C and fasting glucose regularly.
- Adopt a low-glycemic index diet and stay active.
✅ 5. Address Mental Health & Stress
- Chronic stress and depression (common in HIV) can raise cortisol and BP.
- Practice mindfulness, therapy, and sleep hygiene.
🧠 Summary Table: HIV and Heart Disease
| Risk Factor | Effect on Heart |
|---|---|
| Chronic inflammation | Damages arteries, causes plaque buildup |
| ART side effects | Can raise cholesterol and sugar levels |
| Lifestyle (e.g., smoking) | Amplifies risk of heart attack |
| Aging with HIV | Accelerates atherosclerosis |
📌 Final Thoughts
People living with HIV now live longer — but with longevity comes greater vulnerability to chronic illnesses like heart disease. The good news is that with early screening, modern ART, and healthy lifestyle choices, heart disease in HIV-positive individuals is largely preventable.
HIV-positive people are living longer than ever because of therapies that prevent the growth of the virus. But these patients deal with more heart troubles and barriers to treatment than other individuals, according to the American Heart Association (AHA).
A scientific statement published in June 2019 in the journal Circulation highlighted that three-quarters of people over the age of 45 who are living with HIV are experiencing significantly more heart attacks, heart failure, and strokes earlier in life compared with those who don’t have HIV.
“Chronic inflammation and immune activation [or response] appear to be the primary drivers of high heart disease risk in HIV,” says Matthew Feinstein, MD, chair of the writing group for the statement and assistant professor of medicine and preventive medicine at the Feinberg School of Medicine at Northwestern University in Chicago.
He stresses that HIV treatment is essential, not only for controlling the virus, but also for reducing chronic inflammation and problems with immune regulation.
“Several studies have now shown that worse HIV control is associated with higher risks for heart disease,” Dr. Feinstein told Everyday Health. “So the first and most important step in preventing heart disease in HIV is getting the HIV under control with the right medications prescribed by HIV specialists and primary care doctors.”
Addressing Common Heart Disease Factors
The statement authors also observed that people living with HIV more often had factors commonly associated with heart troubles, such as heavy alcohol use, substance abuse, mood and anxiety disorders, low levels of physical activity, and poor cardiorespiratory fitness.
About 4 out of 10 are smokers, according to a nationally representative sample of HIV patients.
Quitting tobacco use, eating a balanced diet (such as the DASH diet or Mediterranean diet), and staying physically active can help lower risk, notes Feinstein.
Sarah Samaan, MD, a cardiologist with Baylor Scott & White Legacy Heart Center in Plano, Texas, who was not an author on the statement, has seen many HIV patients benefit from statin drugs to lower cholesterol and medication to lower blood pressure.
“Since some HIV medications can raise the risk of side effects from other drugs, it’s important to discuss the options for treatment with a knowledgeable physician,” say Dr. Samaan. “A good pharmacist can also help to ensure that the drugs that are prescribed are safe and appropriate.”
Living Longer But With More Health Problems
In an accompanying patient perspective published by the American Heart Association, Jules Levin, the founder and executive director of the National AIDS Treatment Advocacy Project (NATAP), expressed his concerns about the high numbers of serious medical problems in older people with HIV compared with the general population.
According to NATAP, those with HIV over 60 years old have an average of three to seven health conditions in addition to being HIV-positive. Comorbidities include heart attacks, strokes, heart failure, kidney disease, frailty, and bone diseases. Also, many take 12 to 15 drugs daily.
“Most people don’t know that HIV is causing accelerated aging,” says Levin, who has been living with HIV for 35 years. “Within a few years of initial infection, the immune system senescence [deterioration with age] sets in right away. Once people with HIV get into their sixties, they really have a double hit — from aging and from the effects of HIV.”
This is why Levin urges HIV-positive individuals to be screened for cardiovascular troubles as well as bone density, kidney disease, and cognitive impairment.
The scientific statement recommends trying the American Heart Association–American College of Cardiology Atherosclerotic Disease Risk Calculator as one way for getting some idea of your heart disease risk.
Overcoming Barriers to Treatment
Both Feinstein and Levin spotlight the need for improving access to healthcare for people living with HIV. The statement authors pointed out that this population is often stigmatized, and federal and local authorities could make more effort to increase care options for these individuals. Many living with HIV are homebound and cognitively impaired to a degree where they have difficulties paying bills and making decisions.
“What’s most needed are support services and better care in the clinics,” says Levin. “We need to actively demand that federal and local officials address this problem.”
He urges people to contact NATAP to explore ways to take action.
A Call for Further Research
Feinstein and his coauthors based this scientific statement on large observational studies investigating HIV and heart disease.
“But we don’t yet have much in the way of large-scale randomized trial data for heart disease prevention and treatment in HIV,” he says. “Although we have a reasonable understanding of why plaque buildup in the arteries occurs in HIV, we do not have as clear of an understanding of why the heart muscle often becomes dysfunctional or why blood clotting may occur more commonly in HIV.”