CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 3, May/June 2011
AFRICA
117
Editorials
HIV infection and cardiovascular risk in black South
Africans
CMT FOURIE, JM van Rooyen, AE Schutte
The clinical consequences of these subtype variations remain
unclear.
18
Although the risk for the development of cardiovascu-
lar disease has been described in many different HIV-1-
infected populations, data on the risk facing the South African
HIV-infected population is scarce, as most of the research is
done on Caucasians infected with HIV-1 subtype B. Therefore,
the risk of cardiovascular disease in HIV-infected South Africans
and how it is affected by the roll-out programme of ART remains
largely unknown. The various effects of the virus itself – includ-
ing its cardiovascular effects – are also important, since many
HIV-infected South Africans are still without therapy and/or
unaware of their infection status. Various factors seem to contrib-
ute to the latter, such as the lack of knowledge, poverty, stigma,
scepticism and lack of interest.
19
The Hypertension in Africa Research Team (HART) there-
fore individually matched 300 newly identified HIV-infected
Africans from the South African Prospective Urban and Rural
Epidemiology (PURE) study with 300 uninfected controls. They
were matched according to age, gender, body mass index and
locality (urban/rural). The larger PURE study is an epidemio-
logical study that will address questions regarding the cause and
development of cardiovascular risk factors and disease within
populations, including South Africa.
20
A minimum follow up
of 10 years is planned. The South African leg of the study
was performed in the North West Province where a total of
2 010 participants (1 004 urban and 1 006 rural) were randomly
recruited from a rural and urban setting and screened during the
baseline phase in 2005. A follow up on the PURE South Africa
study was done in 2010. The newly identified HIV-infected
participants and their controls of the baseline (2005) study were
also followed up in 2008.
In a cross-sectional analysis on the baseline data we aimed to
evaluate if HIV-1 infection itself is associated with dyslipidae-
mia, inflammation and the occurrence of the metabolic syndrome
in newly identified HIV-1-infected black South Africans who
had never received antiretroviral therapy. We concluded that
HIV-1 is associated with dyslipidaemia and an inflammatory
state in newly identified HIV-infected, never-treated African
individuals and that it may increase their risk for cardiovascular
disease. The study showed that HIV-1, most likely subtype C,
seems to influence the components of the metabolic syndrome
in South Africans in the same way as HIV-1 subtype B does in
Caucasians. It also showed that the virus does not increase the
prevalence of the metabolic syndrome in these never-treated,
HIV-infected South Africans.
21
In this edition of the
Cardiovascular Journal of Africa
, a
The overall growth of the global AIDS epidemic appears to
have stabilised and the number of new infections is declining.
1
This and the significant reduction in mortality could be attrib-
uted to the effectiveness of antiretroviral therapy (ART). Human
immunodeficiency virus (HIV) infection, although still fatal,
has become a chronic and manageable disease. The therapy has
increased the life expectancy of HIV-infected individuals and
therefore more people are living with HIV. The region affected
the most by HIV remains sub-Saharan Africa, and South Africa
continues to be the country housing the largest population of
people (an estimated 5.6 million people in 2009) living with HIV
worldwide.
1
Besides some very uncomfortable side effects due to both
HIV infection and the therapy, another more serious side effect
has emerged, namely an increased risk for cardiovascular disease
(CVD).
2,3
HIV infection paradoxically affects cardiovascular risk
factors and circulatory disease within populations and individu-
als. Researchers have associated HIV infection and especially the
use of ART with an increase in insulin resistance, dyslipidaemia,
4
lipodystrophy
5,6
endothelial dysfunction,
7
accelerated atheroscle-
rosis
8
and coagulation disorders.
9
In the past 15 years SouthAfrica has experienced a rise in non-
communicable diseases, such as cardiovascular disease, which is
predicted to increase in the next decades.
10
This rise in incidence
of non-communicable diseases is masked by the overwhelming
presence of communicable diseases such as HIV and tuberculo-
sis.
11
Therefore, cardiovascular complications in the HIV-infected
population could become a serious health problem in South
Africa by increasing the burden of non-communicable diseases
once patients are receiving ART for longer periods.
11
Recent
research has shown that atherosclerotic disease, historically
not common in black Africans, is increasing in South Africa.
12
The South African HIV-infected population has had access to
free antiretroviral treatment since 2004 and the influence of ART
on the cardiovascular system in this population is not yet estab-
lished. The South African National AIDS Council updated the
HIV treatment guidelines and adopted some of the recent recom-
mendations made by the World Health Organisation (WHO),
which will lead to more people receiving treatment.
13
This expan-
sion of antiretroviral therapy and the effect thereof on the burden
of non-communicable diseases (such as cardiovascular disease)
in South Africa is yet to be determined.
The predominant virus responsible for the infections in South
Africa is HIV-1, group M (major), subtype C,
14,15
which accounts
for 55 to 60% of all HIV-1 infections worldwide,
16
and differs as
much as 30% in its genome from HIV-1 subtype B, responsible
for most infections in North America, Europe and Australia.
14,16,17
