CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
200
AFRICA
Management of HIV-associated vasculopathy requires a
multi-disciplinary approach, with HIV physicians working hand
in hand with vascular surgeons and rehabilitation specialists.
Modification of vasculopathy risk is clearly important for
secondary prophylaxis and includes administration of anti-plate-
let therapy, angiotensin converting enzyme inhibition, and lipid-
lowering therapy. There is no current evidence to support a role
for corticosteroids or other immunosuppressants in the manage-
ment of HIV-associated vasculopathy. A role for thrombolytic
therapy in the acute setting has been proposed.
14
Definitive surgi-
cal management will depend on the manifest vascular pathology,
and includes aneurysm repair, transcatheter embolisation, bypass
procedures, endovascular procedures, thrombo-embolectomy,
and/or amputation.
HIV-associated vasculopathy is not part of the WHO or CDC
staging systems that are commonly used to define who is eligi-
ble to receive ART. We believe that ART forms an essential part
of therapy to prevent disease progression, irrespective of CD
4
T-cell count, and propose that HIV vasculopathy be identified
as a WHO stage IV diagnosis, in keeping with such entities as
HIV-associated nephropathy and HIV-associated cardiomyopathy.
The choice of antiretroviral regimen for patients with vascu-
lopathy should take into account the propensity for individual
antiretrovirals to induce dyslipidaemia and insulin resistance.
Nucleoside and non-nucleoside reverse transcriptase inhibitor
protease inhibitors (PI) can cause increases in total cholesterol,
LDL cholesterol and triglycerides.
15
PIs as a group are commonly
associated with dyslipidaemia and insulin resistance, both of
which are risk factors for arteriosclerosis.
16
If PI-based ART is
required, a once-daily atazanavir-based regimen may be prefer-
able in patients with HIV-associated vasculopathy, as it carries a
lesser risk of dyslipidaemia than other PIs.
17,18
Conclusion
We report on a histologically confirmed case of HIV-associated
vasculopathy in which the option to start early ART and to alter
disease progression was missed. Given the overwhelming burden
of HIV infection in southern Africa, clinicians need to have
a heightened index of suspicion for making the diagnosis of
HIV-associated vasculopathy in young patients presenting with
peripheral arterial disease. Early commencement of ART in the
management of this condition may contribute to improved clini-
cal outcomes in HIV-infected individuals with HIV-associated
vasculopathy.
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