Cerebral small vessel disease (CSVD), defined by white matter hyperintensities (WMHs), silent brain infarction (SBI) or microbleeds (MBs), is a major cause of future vascular events, cognitive impairment, frailty, and poor survival. CSVD is correlated with age and cardiovascular risk factors (CVRF). Little is known on the prevalence of CSVD in persons living with HIV (PLWHIV) with controlled viral load (VL) under cART, who often present conventional and non-conventional CVRFs.
The ANRS EP51 MICROBREAK (NCT02082574) cross-sectional study, conducted in 4 Paris hospitals in France, aimed to assess the prevalence of CSVD detected by MRI in treated PLWHIV, 50 years of age or older, not HCV infected and with controlled VL for at least 12 months, in comparison with HIV negative controls (HNC), with frequency matching on age and sex. Brain 3T MRI included 3D FLAIR, DWI and T2*. All MRI were reviewed by 2 experienced neuroradiologists, blinded to HIV status, using the Fazekas scale for WMHS and Wardlaw’s research criteria for SBI and MBs, with a third reader in case of discordance. We also assessed the impact of HIV on the severity of CSVD defined as WMHs Fazekas 2-3 or SBI or MBs. A logistic regression model was used to assess the impact of HIV on CSVD adjusted on traditional risk factors.
Between June 2013 and May 2016, 456 PLWHIV and 154 HNC were recruited; median age was 56 and 58 years (p=0.001), 84% and 77% (p=0.030) were men, respectively. All CVRF were more frequent in PLWHIV than in HNC (hypertension 33% vs 21%, hypercholesterolemia 41% vs 19% and hypertriglyceridemia 22% vs 6%, respectively), except diabetes (8% vs 5%) and smoking (46% vs 42%). The median CD4 count in PLWHIV was 655/mm3 [IQR: 510 – 845] and 62% had been diagnosed before 1996. CSVD was detected in 51.5% of PLWHIV and 36.4% of HNC, with an adjusted odds ratio (ORa) of 2.3 (95% confidence interval: 1.5–3.6). Severe CSVD was observed in 19% of PLWHIV and 14% of HNC, with an ORa of 1.6 (0.9–2.7). As expected, older age and hypertension were also associated with the risk of CSVD. The impact of HIV was different according to age, with ORa of 5.3 (1.7–16.3), 3.7 (1.7–8.0) and 1.0 (0.5–2.2) for age of <54, 54-60 and >60 years, respectively (p=0.022).
Despite cART-sustained immunovirologic control, the prevalence of CSVD is twice higher in middle-aged PLWHIV. Besides age and hypertension, HIV is an independent risk factor of CSVD.