CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 AFRICA 59 Interestingly, in the Heart of Soweto study, Sliwa et al. (2012) evaluated the presentation of 515 PHIV (62% women, average 39 years and 54% on ART). Of all cardiovascular disease presentations, a significant proportion was caused by dilated cardiomyopathy (38%) and pericarditis (25%), and no cases of HFpEF were noted.140,153 In contrast, studies of predominantlymale cohorts of American PHIV with heart failure (US Veterans Cohort, US Mon Cohort) showed a near equal number of those diagnosed with HFrEF and HFpEF.140,154,155 In addition, Janjua’s analysis of American WHIV with heart failure (Partners Healthcare cohort) showed a significant number of patients with HFpEF.140,156 Of significance, the average age in the US cohort as well as the numbers treated with ARVs were higher compared to the South African cohort. Of note, a meta-analysis by Cerrato et al. (2013) of cardiac dysfunction among PHIV, which included 11 studies (one from North Africa, one from Asia, six from Europe and three from North America) and was published between 2004 and 2011, showed a prevalence of diastolic dysfunction of 43.38%; the prevalence of systolic dysfunction was 8.33%. This study included 2 242 PHIV with a median age of 42 years and 98% were on ARVs, 74% of whom had an undetectable viral load.140,157 These findings underscore the heterogeneity of cardiovascular manifestations in HIV and an evolution of disease depending on factors such as age, gender and treatment, and increased prevalence of usual cardiovascular risk factors in the population. The incidence of HFpEF is increasing and will soon be the predominant form of heart failure. These findings are interesting as they raise myriad questions as to why the changes occur depending on the metabolic and transcriptomic alterations associated with HIV. Do these changes translate to dynamic changes in systemic vasculature and PE? This brings forth new avenues for research to investigate the underlying molecular changes, which would enhance our understanding and may lead to the development of new therapies. HIV, cardiovascular disease and PE Dennis et al. (2015) found that patients with HIV at term on echocardiographic assessment showed reductions in cardiac index, left and right systolic myocardial velocities and increased left ventricular end-diastolic areas. This could be related to the disease itself or treatment of the disease, or the effects of pregnancy on the cardiovascular system.106 There is a paucity of data on cardiac function in PE patients with HIV infection, and whether cardiac dysfunction is amplified by dual pathology, whether or not severity of PE or CD4 count plays a role in severity of cardiac manifestations and whether or not treatment of HIV ameliorates or exacerbates the cardiovascular disease manifestations. 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