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HIV-Associated Pulmonary Arterial Hypertension Defies ART

A large case series suggests that the prognosis of PAH is not dramatically altered by effective combination antiretroviral therapy.

Pulmonary arterial hypertension (PAH) is a rare complication of HIV infection and one of the few in which incidence seems unrelated to stage of infection and degree of immunodeficiency. Does effective antiretroviral therapy (ART) influence the prognosis of PAH? A report from a large referral center in France suggests that good HIV treatment may be less important than good PAH treatment.

Between 2000 and 2008, 77 (8%) of nearly 1000 patients with PAH (confirmed by right heart catheterization) had HIV infection as their only risk factor. A minority were injection-drug users (36%). At the time of PAH diagnosis, 38 patients (49%) had undetectable viral loads, and 61 (79%) had CD4 counts >200 cells/mm³; most patients were receiving combination ART. After diagnosis, all patients received ART, and 50 received what the authors considered "first-line" PAH treatment (epoprostenol, iloprost, bosentan, or a calcium-channel blocker, either singly or in combination).

Mortality rates were 12% at 1 year of follow-up, 28% at 3 years, and 37% at 5 years. There were 12 deaths among the 27 patients (44%) who did not receive PAH treatment at diagnosis, compared with 14 among the 50 (28%) who did. Overall, causes of death were pretty evenly split between consequences of PAH (58%) and other reasons, including AIDS (42%). Patients with poorly controlled HIV infection tended to die of causes other than PAH. In a multivariate analysis, the only independent risk factors for mortality were cardiac index <2.8 L/min/m² and CD4 count <200 cells/mm³.

Comment: This report confirms that HIV-related PAH can develop in patients with well-controlled HIV infection and that state-of-the art HIV treatment will not arrest the progress of the disease, although the authors believe that ART might have slowed the downhill course somewhat. They conclude that perhaps initiating specific PAH treatment early in the course of illness is the key to longer survival among HIV-infected patients with this condition.

— Abigail Zuger, MD

Published in Journal Watch HIV/AIDS Clinical Care October 9, 2009

Citation(s):

Degano B et al. HIV-associated pulmonary arterial hypertension: Survival and prognostic factors in the modern therapeutic era. AIDS 2009 Sep 16; [e-pub ahead of print]. (http://tinyurl.com/ylynrcr)

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