Background
People living with HIV (PLWH) face an elevated risk for atherosclerotic cardiovascular disease (ASCVD). Coronary artery calcium (CAC) scores, a marker of subclinical atherosclerosis, strongly predict ASCVD. Identifying drivers of CAC progression can guide more aggressive preventive strategies for this at risk population.
Methods
This cohort study enrolled Thai PLWH aged 50-60 years without established ASCVD from HIV-NAT, Thailand. Baseline data collection included 10-year ASCVD risk, smoking and alcohol consumption status, HIV-related parameters, metabolic profiles, inflammatory markers, and statin use. For this analysis, we included only participants who underwent two CAC assessment: at baseline (2015-2018) and during follow-up (2023-2024) to assess progression across CAC score categories (0, >0-99, 100-399, ≥400). Multivariable logistic regression was used to identify associations with CAC score progression.
Results
Of 220 participants, 112 (51%) experienced CAC progression over a median follow-up of 6.9 years (IQR 6.6-7.4). Progressors were more likely to be male (69.6% vs. 45.4%, p<0.001), current smokers (15.2% vs. 7.4%, p<0.001), drink alcohol (25.9% vs. 9.3%, p=0.001), have intermediate to high 10-year ASCVD risk (45.5% vs. 26.6%, p=0.001), high triglycerides (57.1% vs. 41.5%, p=0.02), and were more likely to use protease inhibitors (PI) (43.8% vs. 30.6%, p=0.04). In participants with a baseline CAC score of 0 (n=125), 44% progressed to >0-99, 4.8% to 100-399, and 0.8% to ≥400. Among those with a baseline score of >0-99 (n=73), 43.8% progressed to 100-399, and 11% to ≥400. For participants with baseline CAC 100-399 (n=11), 91% progressed to ≥400. All participants with baseline scores ≥400 (n=11) remained in this category at follow-up. In a multivariable model, BMI ≥25 kg/m² (OR 2.1, 95% CI 1.1-4.2, p=0.03) smoking (OR 2.8, 95% CI 1.6-6.0, p=0.01) and high triglyceride-glucose (TyG) Index (OR 1.8, (95%CI 1.1-3.2), p=0.03) were independently associated with CAC progression. Compared to those taking NNRI, PI or intergrase inhibitor-based regimens were not statistically significant but were associated with increased risk (Figure).
Conclusions
More than 50% of participants showed worsened subclinical atherosclerosis, with greater progression rates in those with higher baseline CAC scores. In addition to statin use, prioritizing smoking cessation and weight management is essential to prevent CAC progression and reduce cardiovascular risk in high-risk PLWH populations.