Cardiovascular disease (CVD) is expected to contribute the largest non-communicable disease burden amongst HIV-positive people over the coming decades. We modeled the impact of different CVD prevention interventions in Dutch HIV-positive patients and determined which is best use of resources.
An individual-based model of CVD in ageing Dutch HIV-positive patients was constructed using 1996-2010 data from 8,791 patients on combination antiretroviral therapy (cART) from the national ATHENA cohort. The model follows patients in care, including new patients, as they age, develop (risk factors for) CVD (by incorporating the D:A:D CVD risk equation) and start CVD medication, and was validated on 2010-2015 data. Four interventions were evaluated between 2017 and 2030, assuming 100% and 50% implementation success: 1) reducing the number of late presenters (i.e. CD4 count <500 cells/mm³); 2) use of cART with no known increased CVD risk; 3) a smoking cessation program; 4) intensified monitoring and drug treatment of hypertension and dyslipidemia. Interventions were evaluated in all patients and in moderate to high CVD risk patients only (HR, 5-year CVD risk ≥5%). Economic evaluations were performed assuming 50% implementation success, accounting for all costs related to HIV/CVD treatment.
The model predicts that CVD incidence will increase by 50% between 2015 and 2030 and that intensified monitoring and treatment of hypertension and dyslipidemia will have the greatest impact on averting CVD events, followed by a smoking cessation program (Figure). Economic evaluations identified three interventions with the potential to be cost-effective: smoking cessation in HR patients, decreasing the number of late presenters in all patients, and intensified monitoring and treatment of hypertension and dyslipidemia in HR patients. The latter is most likely to be the best use of resources and could be cost-effective or even cost-saving.
Our study is the first to provide evidence to guide policy makers concerning which high-impact CVD prevention interventions to prioritize as part of HIV care, recommending intensified monitoring and successful treatment of hypertension and dyslipidemia in moderate to high CVD risk patients as the best use of resources by focusing on addressing the gap between current clinical care and standard guidelines. Quantifying additional public health benefits, beyond CVD, of all four interventions, is likely to provide further evidence for policy development.