HIV‐Associated Heart Failure: Phenotypes and Clinical Outcomes in a Safety‐Net Setting

Background HIV is associated with increased risk of heart failure (HF) but data regarding phenotypes of HF and outcomes after HF diagnosis, especially within the safety net where half of people with HIV in the United States receive care, are less clear. Methods and Results Using an electronic health record cohort of all individuals with HF within a municipal safety‐net system from 2001 to 2019 linked to the National Death Index Plus, we compared HF phenotypes, all‐cause mortality, HF hospitalization, and cause of death for individuals with and without HIV. Among people with HF (n=14 829), 697 individuals had HIV (4.7%). People with HIV were diagnosed with HF 10 years younger on average. A higher proportion of people with HIV had a reduced ejection fraction at diagnosis (37.9% versus 32.7%). Adjusted for age, sex, and risk factors, coronary artery disease on angiography was similar by HIV status. HIV was associated with 55% higher risk of all‐cause mortality (hazard ratio [HR], 1.55 [95% CI, 1.37–1.76]; P <0.001) and lower odds of HF hospitalization (odds ratio [OR], 0.51 [95% CI, 0.39–0.66]; P <0.001). Among people with HIV with HF, cause of death was less often attributed to cardiovascular disease (22.5% versus 54.6% uninfected; P <0.001) and more to substance use (17.9% versus 9.3%; P <0.001), consistent with autopsy findings in a subset (n=81). Conclusions Among people with HF who receive care within a municipal safety‐net system, HIV infection is associated with higher mortality, despite lower odds of HF hospitalization, attributable to noncardiovascular causes including substance‐related and HIV‐related mortality.