HIV and cardiovascular diseases: a systematic review and comparative risk assessment study

Background People living with HIV (PLWH) face a significantly elevated risk of cardiovascular diseases (CVDs). This study aims to quantify temporal trends in HIV-attributable CVD burden at global, regional and national levels using a comparative risk assessment framework. Methods We systematically searched PubMed, Embase and MEDLINE for cohort studies from inception to 28 October 2024, assessing HIV infection and CVD risk. Pooled risk ratios (RRs) for total and subtype-specific CVDs were estimated using random-effects meta-analysis. Based on pooled RRs and HIV prevalence data from the Global Burden of Disease (GBD) 2021 study, we calculated population attributable fractions (PAFs) from 1990 to 2011. These PAFs were applied to GBD disability-adjusted life-years (DALYs) to estimate the age-standardised DALYs rate (ASDRs) of CVDs attributable to HIV by sex, region and year between 2000 and 2021. Findings 35 cohort studies with 199 effect estimates were included. HIV infection was associated with increased risk of total CVDs (RR=1.38), stroke (1.90), ischaemic stroke (1.31), haemorrhagic stroke (2.04), ischaemic heart disease (1.72), myocardial infarction (1.60), heart failure (1.71), peripheral vascular disease (1.19) and cardiac arrest (2.58). Subgroup analyses showed higher ischaemic stroke risk in females and increased CVD risk among PLWH with low CD4+ or high viral load. From 1990 to 2011, the global PAF for total CVDs attributable to HIV rose from 0.0814% to 0.2244%. Global ASDR attributable to HIV nearly tripled, increasing from 3.45 to 9.26 per 100 000 population between 2000 and 2021, with stroke and ischaemic heart disease contributing most. The burden was highest in low-Sociodemographic Index regions, particularly southern Africa; in 2021, Lesotho and Eswatini had the highest ASDRs. Interpretation HIV-attributable CVD burden has risen substantially over the past two decades, with marked concentration in the African Region. Integrating CVD screening and management into HIV care is urgently needed in high-prevalence settings.