Background
People with HIV (PWH) have an increased risk of heart failure (HF), and HF outcomes among PWH are worse than in persons without HIV. Guideline-directed medical therapy (GDMT) is the cornerstone of HF management but is often suboptimally prescribed. Despite poor HF outcomes in PWH, little is known about GDMT prescription among PWH with HF.
Methods
We conducted retrospective analyses of the PATHWAYS study, a multi-institutional observational study of underrepresented racial and ethnic groups in the Southern U.S. from 2014-2020. Adult patients with a systolic HF ICD-9 or ICD-10 code on or after the first date of HIV diagnosis were included. A composite 3+ pillar GDMT score was constructed using dosage-weighted prescription of GDMT drugs (beta-blockers [BB], renin-angiotensin system [RAS] inhibitors, mineralocorticoid receptor antagonists [MRA], and hydralazine [for Black patients only]), with a maximum score of 100% indicating optimal GDMT (Table 1). Covariates of interest included age, sex, social deprivation index [SDI], rural address, insurance type, HIV characteristics, ambulatory clinic visits, and select comorbidities. Among patients with systolic HF, associations between covariates and the maximum GDMT score within one year of HF diagnosis were estimated using unadjusted means ratios.
Results
Among 451 PWH with systolic HF, the median age was 54 years (interquartile range [IQR] 47-62), 34.6% were female, 96.6% were Black, and 3.6% were Hispanic. The median CD4 count was 332 (IQR 173-618). Prescription of any GDMT occurred in 85.8% of patients. Overall, 74.5% of patients were prescribed BB, 58.8% were prescribed RAS inhibitors, 22.2% were prescribed MRA, and 21.4% of eligible patients were prescribed hydralazine. The mean GDMT score was 30% (standard deviation [SD] 22%). Lower average GDMT scores occurred in patients with higher SDI scores (0.97, 95% CI: 0.94-0.99) and severe renal disease (0.84, 95% CI: 0.72, 0.99). Higher average GDMT scores occurred in patients with diabetes mellitus (unadjusted mean ratio 1.25, 95% confidence interval [CI] 1.09-1.44), hypertension (1.39, 95% CI: 1.14-1.69), elevated LDL cholesterol (1.34, 95% CI; 1.06-1.69), obesity (1.16, 95% CI: 1.00-1.35), and prior myocardial infarction (1.18, 95% CI: 1.02-1.36).
Conclusions
People with HIV and HF had low GDMT scores, indicating suboptimal intensity of HF care. Further studies are needed to investigate potential disparities in GDMT prescription among people with and without HIV.