Letters to the Editor
Regarding: Cardiovascular Risk-factor Knowledge and Risk Perception Among HIV-infected Adults To the Editor:
Much research focuses on the increased rate of cardiovascular disease (CVD) among people living with HIV infection (PLWH). A great deal of this research aims to understand the mechanism of increased risk that leads to morbidity and early mortality in this population. The recent article by Cioe, Crawford, and Stein (2014), focusing on the knowledge of CVD risk factors and perceived and estimated risk, is timely and important for increasing awareness on the human aspects, as opposed to strictly biological mechanisms, that may be significant in understanding CVD in PLWH. However, several aspects of CVD risk were not addressed. First, the authors estimated CVD risk by calculating a Framingham Risk Score (FRS), a score that underestimates risk for CVD in those with HIV. This underestimation is due to additional comorbidities prevalent in PLWH that are not accounted for in the FRS framework. I am left wondering why the authors did not use the Data Collection on Adverse Effects of AntiHIV Drugs (D:A:D) risk equation, which was tailored for the HIV-infected population to assess CVD risk and has been used to produce a more accurate estimate compared to the FRS (Serrano-Villar et al., 2012). Second, because diabetes is a well-documented risk factor for CVD that is not included in the FRS, the authors included it as a risk outside of the traditional factors. However, hepatitis C co-infection, known to increase inflammation and CVD (Bedimo et al., 2010) and present among nearly 50% of the sample, was not included. Third, the established risk factors of depression and alcohol use should also have been included, as both are strong predictors of CVD (Freiberg et al., 2010; Goldston & Baillie, 2008). Depression affects as many as 47.8% of PLWH (Chander, Himelhoch, & Moore, 2006). Additionally, those with HIV have
nearly twice the rate of heavy drinking compared to the general population (Galvan et al., 2002). It is time that these variables are included as independent risk factors in studies investigating the relationship between HIV and CVD. Lastly, a strategy of dissemination includes making the research participant aware of the study results. It seems particularly applicable here, as the authors suggested that risk-factor knowledge is an important construct in increasing accurate risk perception and reducing risk. I wonder if the authors used this teachable moment to let the participants know what risk factors they featured and to offer resources that might be useful in reducing or eliminating these risks.
Disclosures The author reports no real or perceived vested interests that relate to this article that could be construed as a conflict of interest. Natalie E. Kelso, MSW PhD student Department of Epidemiology College of Health and Health Professions College of Medicine University of Florida Gainesville, Florida, USA
References Bedimo, R., Westfall, A. O., Mugavero, M., Drechsler, H., Khanna, N., & Saag, M. (2010). Hepatitis C virus coinfection and the risk of cardiovascular disease among HIV-infected patients. HIV Medicine, 11(7), 462-468. http://dx.doi. org/10.1111/j.1468-1293.2009.00815.x Chander, G., Himelhoch, S., & Moore, R. D. (2006). Substance abuse and psychiatric disorders in HIV-positive patients.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 25, No. 2, March/April 2014, 105-107 Copyright Ó 2014 Association of Nurses in AIDS Care
106 JANAC Vol. 25, No. 2, March/April 2014 Epidemiology and impact on antiretroviral therapy. Drugs, 66(6), 769-789. http://dx.doi.org/10.2165/00003495-200666 060-00004 Cioe, P. A., Crawford, S. L., & Stein, M. D. (2014). Cardiovascular risk-factor knowledge and risk perception among HIVinfected adults. Journal of the Association of Nurses in AIDS Care, 25(1), 60-69. http://dx.doi.org/10.1016/j.jana.2013.07. 0066 Freiberg, M. S., McGinnis, K. A., Kraemer, K., Samet, J. H., Conigliaro, J., Ellison, R. C., . Justice, A. C. (2010). The association between alcohol consumption and prevalent cardiovascular diseases among HIV-infected and HIVuninfected men. Journal of Acquired Immune Deficiency Syndromes, 53(2), 247-253. http://dx.doi.org/10.1097/QAI. 0b013e3181c6c4b7 Galvan, F. H., Bing, E. G., Fleishman, J. A., London, A. S., Caetano, R., Burnam, M. A., . Shapiro, M. (2002). The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: Results from the HIV cost and services utilization study. Journal of Studies on Alcohol, 63(2), 179-186. Goldston, K., & Baillie, A. J. (2008). Depression and coronary heart disease: A review of the epidemiological evidence, explanatory mechanisms and management approaches. Clinical Psychology Review, 28(2), 288-306. http://dx.doi.org/10. 1016/j.cpr.2007.05.005 Serrano-Villar, S., Estrada, V., Gomez-Garre, D., Avila, M., Fuentes-Ferrer, M., San Roman, J., . Fernandez-Cruz, A. (2012). Diagnosis of subclinical atherosclerosis in HIV-infected patients: Higher accuracy of the D: A:D risk equation over Framingham and SCORE algorithms. European Journal of Preventive Cardiology http://dx.doi. org/10.1177/2047487312452964 [Epub ahead of print]. http://dx.doi.org/10.1016/j.jana.2013.11.005
Reply to the Editor:
We would like to respond to Ms. Kelso’s letter to the editor regarding our recent publication in JANAC entitled, ‘‘Cardiovascular Risk-Factor Knowledge and Risk Perception Among HIV-Infected Adults’’ (Cioe, Crawford, & Stein, 2014). As HIV health care providers and researchers, we agree that understanding HIV-infected patients’ cardiovascular risk perceptions and risk-factor knowledge is paramount to the development of patient-centered treatment strategies. Our article presented the main outcome findings from our initial study of this important area of research. While we discussed in our manuscript that the Framingham Risk Score had limitations in this population and that some have suggested that it may underestimate risk, we chose to use it for several rea-
sons. Firstly, the calculation can be made quickly in an office setting, with routinely available clinical values, making it a practical and useful tool for assessment and teaching during a patient encounter. We wanted our study to mirror provider behaviors that might occur in clinical practice. Secondly, our data collection preceded the publication of the Serrano-Villar et al. (2012) article to which Ms. Kelso referred. Our study was conducted early in 2011 and its methods were consistent with many previous studies that used the Framingham Risk Score to estimate risk; we refer Ms. Kelso to Bergersen, Sandvik, Bruun, & Tonstad (2004); Falcone et al. (2011); Glass et al. (2006); Hadigan et al. (2003); and Lo et al. (2010). We agree that diabetes is a significant and established cardiovascular risk factor; in fact, it is recognized as a cardiovascular risk equivalent per the 2002 National Cholesterol Education Program expert panel (National Cholesterol Education Program, 2002). According to these guidelines, any adult with a diagnosis of diabetes is at high risk for a cardiac event. We accepted this definition for our study and categorized diabetic patients accordingly. Conversely, hepatitis C, depression, and heavy alcohol use have been associated with an increased incidence of cardiac events in some recent studies; however, they have not been accepted as established risk factors for cardiovascular disease. In the Bedimo et al. (2010) article to which Ms. Kelso referred, hepatitis C co-infection was strongly associated with hypertension, diabetes, and cigarette smoking (all known risk factors for cardiovascular disease). In multivariate analyses, however, controlling for these accepted risk factors, the association between hepatitis C co-infection and acute myocardial infarction was no longer significant (p 5 .072). Finally, we agree that dissemination of this information to patients and translation of these findings to clinical practice is the ultimate goal of patientcentered research. Cardiac risk was discussed with participants during the study visits. Participants were provided with resources to access additional information, and lastly, they were referred to their HIV health care providers for further assessment and information. We hope Ms. Kelso finds our response helpful. We thank her for her careful consideration of our
Regarding: Cardiovascular Risk-factor Knowledge and Risk Perception Among HIV-infected Adults To the Editor:
Much research focuses on the increased rate of cardiovascular disease (CVD) among people living with HIV infection (PLWH). A great deal of this research aims to understand the mechanism of increased risk that leads to morbidity and early mortality in this population. The recent article by Cioe, Crawford, and Stein (2014), focusing on the knowledge of CVD risk factors and perceived and estimated risk, is timely and important for increasing awareness on the human aspects, as opposed to strictly biological mechanisms, that may be significant in understanding CVD in PLWH. However, several aspects of CVD risk were not addressed. First, the authors estimated CVD risk by calculating a Framingham Risk Score (FRS), a score that underestimates risk for CVD in those with HIV. This underestimation is due to additional comorbidities prevalent in PLWH that are not accounted for in the FRS framework. I am left wondering why the authors did not use the Data Collection on Adverse Effects of AntiHIV Drugs (D:A:D) risk equation, which was tailored for the HIV-infected population to assess CVD risk and has been used to produce a more accurate estimate compared to the FRS (Serrano-Villar et al., 2012). Second, because diabetes is a well-documented risk factor for CVD that is not included in the FRS, the authors included it as a risk outside of the traditional factors. However, hepatitis C co-infection, known to increase inflammation and CVD (Bedimo et al., 2010) and present among nearly 50% of the sample, was not included. Third, the established risk factors of depression and alcohol use should also have been included, as both are strong predictors of CVD (Freiberg et al., 2010; Goldston & Baillie, 2008). Depression affects as many as 47.8% of PLWH (Chander, Himelhoch, & Moore, 2006). Additionally, those with HIV have
nearly twice the rate of heavy drinking compared to the general population (Galvan et al., 2002). It is time that these variables are included as independent risk factors in studies investigating the relationship between HIV and CVD. Lastly, a strategy of dissemination includes making the research participant aware of the study results. It seems particularly applicable here, as the authors suggested that risk-factor knowledge is an important construct in increasing accurate risk perception and reducing risk. I wonder if the authors used this teachable moment to let the participants know what risk factors they featured and to offer resources that might be useful in reducing or eliminating these risks.
Disclosures The author reports no real or perceived vested interests that relate to this article that could be construed as a conflict of interest. Natalie E. Kelso, MSW PhD student Department of Epidemiology College of Health and Health Professions College of Medicine University of Florida Gainesville, Florida, USA
References Bedimo, R., Westfall, A. O., Mugavero, M., Drechsler, H., Khanna, N., & Saag, M. (2010). Hepatitis C virus coinfection and the risk of cardiovascular disease among HIV-infected patients. HIV Medicine, 11(7), 462-468. http://dx.doi. org/10.1111/j.1468-1293.2009.00815.x Chander, G., Himelhoch, S., & Moore, R. D. (2006). Substance abuse and psychiatric disorders in HIV-positive patients.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 25, No. 2, March/April 2014, 105-107 Copyright Ó 2014 Association of Nurses in AIDS Care
106 JANAC Vol. 25, No. 2, March/April 2014 Epidemiology and impact on antiretroviral therapy. Drugs, 66(6), 769-789. http://dx.doi.org/10.2165/00003495-200666 060-00004 Cioe, P. A., Crawford, S. L., & Stein, M. D. (2014). Cardiovascular risk-factor knowledge and risk perception among HIVinfected adults. Journal of the Association of Nurses in AIDS Care, 25(1), 60-69. http://dx.doi.org/10.1016/j.jana.2013.07. 0066 Freiberg, M. S., McGinnis, K. A., Kraemer, K., Samet, J. H., Conigliaro, J., Ellison, R. C., . Justice, A. C. (2010). The association between alcohol consumption and prevalent cardiovascular diseases among HIV-infected and HIVuninfected men. Journal of Acquired Immune Deficiency Syndromes, 53(2), 247-253. http://dx.doi.org/10.1097/QAI. 0b013e3181c6c4b7 Galvan, F. H., Bing, E. G., Fleishman, J. A., London, A. S., Caetano, R., Burnam, M. A., . Shapiro, M. (2002). The prevalence of alcohol consumption and heavy drinking among people with HIV in the United States: Results from the HIV cost and services utilization study. Journal of Studies on Alcohol, 63(2), 179-186. Goldston, K., & Baillie, A. J. (2008). Depression and coronary heart disease: A review of the epidemiological evidence, explanatory mechanisms and management approaches. Clinical Psychology Review, 28(2), 288-306. http://dx.doi.org/10. 1016/j.cpr.2007.05.005 Serrano-Villar, S., Estrada, V., Gomez-Garre, D., Avila, M., Fuentes-Ferrer, M., San Roman, J., . Fernandez-Cruz, A. (2012). Diagnosis of subclinical atherosclerosis in HIV-infected patients: Higher accuracy of the D: A:D risk equation over Framingham and SCORE algorithms. European Journal of Preventive Cardiology http://dx.doi. org/10.1177/2047487312452964 [Epub ahead of print]. http://dx.doi.org/10.1016/j.jana.2013.11.005
Reply to the Editor:
We would like to respond to Ms. Kelso’s letter to the editor regarding our recent publication in JANAC entitled, ‘‘Cardiovascular Risk-Factor Knowledge and Risk Perception Among HIV-Infected Adults’’ (Cioe, Crawford, & Stein, 2014). As HIV health care providers and researchers, we agree that understanding HIV-infected patients’ cardiovascular risk perceptions and risk-factor knowledge is paramount to the development of patient-centered treatment strategies. Our article presented the main outcome findings from our initial study of this important area of research. While we discussed in our manuscript that the Framingham Risk Score had limitations in this population and that some have suggested that it may underestimate risk, we chose to use it for several rea-
sons. Firstly, the calculation can be made quickly in an office setting, with routinely available clinical values, making it a practical and useful tool for assessment and teaching during a patient encounter. We wanted our study to mirror provider behaviors that might occur in clinical practice. Secondly, our data collection preceded the publication of the Serrano-Villar et al. (2012) article to which Ms. Kelso referred. Our study was conducted early in 2011 and its methods were consistent with many previous studies that used the Framingham Risk Score to estimate risk; we refer Ms. Kelso to Bergersen, Sandvik, Bruun, & Tonstad (2004); Falcone et al. (2011); Glass et al. (2006); Hadigan et al. (2003); and Lo et al. (2010). We agree that diabetes is a significant and established cardiovascular risk factor; in fact, it is recognized as a cardiovascular risk equivalent per the 2002 National Cholesterol Education Program expert panel (National Cholesterol Education Program, 2002). According to these guidelines, any adult with a diagnosis of diabetes is at high risk for a cardiac event. We accepted this definition for our study and categorized diabetic patients accordingly. Conversely, hepatitis C, depression, and heavy alcohol use have been associated with an increased incidence of cardiac events in some recent studies; however, they have not been accepted as established risk factors for cardiovascular disease. In the Bedimo et al. (2010) article to which Ms. Kelso referred, hepatitis C co-infection was strongly associated with hypertension, diabetes, and cigarette smoking (all known risk factors for cardiovascular disease). In multivariate analyses, however, controlling for these accepted risk factors, the association between hepatitis C co-infection and acute myocardial infarction was no longer significant (p 5 .072). Finally, we agree that dissemination of this information to patients and translation of these findings to clinical practice is the ultimate goal of patientcentered research. Cardiac risk was discussed with participants during the study visits. Participants were provided with resources to access additional information, and lastly, they were referred to their HIV health care providers for further assessment and information. We hope Ms. Kelso finds our response helpful. We thank her for her careful consideration of our
