Prevention of cardiovascular disease for historically marginalized racial and ethnic groups living with HIV: A narrative review of the literature☆

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Abstract

Despite developments to improve health in the United States, racial and ethnic disparities persist. These disparities have profound impact on the wellbeing of historically marginalized racial and ethnic groups. This narrative review explores disparities by race in people living with cardiovascular disease (CVD) and the Human Immunodeficiency Virus (HIV). We discuss selected common social determinants of health for both of these conditions which include; regional historical policies, incarceration, and neighborhood effects. Data on racial disparities for persons living with comorbid HIV and CVD are lacking. We found few published articles (n = 7) describing racial disparities for persons living with both comorbid HIV and CVD. Efforts to reduce CVD morbidity in historically marginalized racial and ethnic groups with HIV must address participation in clinical research, social determinants of health and translation of research into clinical practice.

Section snippets

Disparities in CVD and risk factors

CVD is the leading cause of death in the US.6,7 Although CVD mortality rates have declined in recent years due to advances in care, rates for African -Americans have largely remained stable.8 Sixty percent of African-American men and 57% of African-American women have some form of CVD.7 Among the different historically marginalized racial and ethnic groups, African-American females have the highest overall death rate from CVD, with 32.8% attributable mortality from this condition.7

Disparities in HIV

It is estimated that there are over 1 million people were living with diagnosed HIV-infection in the US in 2017.5 While African-Americans make up only 13% of the overall US population, this group accounts for 41% of people living with HIV and 41% of new HIV diagnoses.5 From 2013 to 2017, the rate of new diagnoses increased for American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders, remained stable for Asians and Hispanics, and decreased for African-Americans and Whites. Over the

Social determinants of health

Common roots of health disparities faced by historically marginalized racial and ethnic groups with HIV and CVD can be evaluated through the social determinants of health framework.12 Social determinants of health are conditions in the environments in which people live, learn, work, play, and worship that affect a wide range of health, functioning, and quality of life outcomes and risks.12 The neighborhood where one lives can affect health through the social environment e.g. high crime rate,

Neighborhood effects

The neighborhood where one lives has a direct impact on health and related CVD and HIV disparities in several ways. Disproportionate investments in parks and green space, which provide more opportunities to exercise safely, have been positively associated with elevated CVD risk.20 Using HIV surveillance data, Xia et al. found that compared with African-Americans living in the most impoverished neighborhoods, Whites in the most impoverished neighborhoods and Blacks in the least impoverished

Regional historical policies

The U.S history of legalized slavery, sharecropping and Jim Crow segregation has led to persistent racial inequality and discrimination.22 Furthermore, medical mistrust among Black populations due to the legacies of the Tuskegee and other experiments remains high in some settings, which can contribute to lower health seeking behaviors for HIV and CVD.23,24 This social inequity can exacerbate disparities in social determinants of health and subsequent health outcomes.

In the U.S., it is estimated

Incarceration

Incarceration has been shown to negatively impact both HIV and CVD outcomes, and approximately 40% of those incarcerated in the US are African-American.30 This disproportionate incarceration of African-Americans has been shown to negatively influence sexual networks in African-American communities, leading to higher rates of concurrent sexual relationships, a risk factor for HIV transmission. Moreover, people tend to choose sexual partners of the same race which leads to further HIV

Unemployment

In 2018, the overall unemployment rate in the U.S. was 3.9%. Unemployment rates were higher for American Indians/Alaska Natives (6.6%), African-American (6.5%), Native Hawaiians/Other Pacific Islanders (5.4%), and Hispanics (4.7%) compared to the US overall.34 Unemployment may lead to many downstream effects like loss of insurance coverage and also food insecurity. Those dealing with food insecurity have lower likelihood of achieving HIV viral suppression and may be more likely to engage in

Poverty

In 2014, it was estimated that almost 15% of the U.S. population was living in poverty, although there were striking differences by race/ethnicity; 28.3% of Native Americans, 26.2% of African-Americans, 23.6% of Hispanics, 12% of Asians, and 10% of Whites were estimated to be living in poverty.37 High poverty rates have been shown to correlate with a higher burden of many diseases, including HIV.38 Poverty, in turn, can contribute to suboptimal education, unstable housing, food insecurity, poor

Disparities within disparities for historically marginalized racial and ethnic groups with CVD and HIV

When individuals from historically marginalized racial and ethnic groups living with HIV have CVD, they experience an additive, if not synergistic impact on health disparities. This raises another dimension of “disparities within disparities” faced by historically marginalized racial and ethnic groups between and within the individual diseases. For example, African-Americans living with HIV have been found to have more poorly controlled BP/HTN, DM and lipid management compared to Whites living

Inattention to racial disparities in CVD among Historically Marginalized Racial and Ethnic Groups with HIV

Those from historically marginalized racial and ethnic groups living with HIV and CVD endure particular health disparities and therefore it is imperative for the research community to focus on reducing this disparities gap. In order to describe the representativeness of historically marginalized racial and ethnic groups in studies from large HIV cohorts, we examined the race distribution of some of the largest studies that evaluated the association of HIV with risk for myocardial infarction

Implications for future research

As efforts to reduce CVD morbidity in people living with HIV expand, we must intentionally include strategies for vulnerable groups such as historically marginalized racial and ethnic groups. A comprehensive research agenda to mitigate differences in CVD outcomes among historically marginalized racial and ethnic groups with HIV is likely to fill major gaps in knowledge and ultimately help achieve health equity. As in other research domains, racial and ethnic differences exist in recruitment,

Participation in clinical research

In response to disparities in participation in clinical research, the National Institutes of Health passed the 1993 Revitalization Act which was intended, among other aims, to diversify research populations. Yet, the promise of the act has not been fulfilled as non-white racial groups remain grossly underrepresented in cardiovascular research.62 The most commonly cited barriers to participating in clinical research among historically marginalized racial and ethnic groups are knowledge,

Social determinants of health

People living with HIV face unique barriers to optimal cardiovascular health as a result of numerous social determinants of health spanning the socio-political context, socioeconomic position, material circumstances and social capital. The burden of these factors - when they present as barriers - has been described in the setting of clinical studies for a variety of racial and ethnic groups living with HIV.45,46,69 These barriers have also been well articulated by HIV treatment advocates from

Translation to clinical practice

Methods to promote adoption and implementation of known effective therapies for CVD must be deployed specifically for historically disenfranchised racial and ethnic groups. The inequities in treatment and testing for CVD in the historically marginalized racial and ethnic groups with HIV have been well-described.45 Owing to the multi-level nature of the disparities in CVD care, programs to improve CVD care should be transdisciplinary, addressing both the biomedical and social determinants of

Conclusion

In this narrative review we evaluated common origins of racial disparities for CVD and HIV. We further demonstrated how social determinants of health can, in part, explain these observed disparities. Racial and ethnic disparities place individuals at a higher risk for both acquiring HIV and developing CVD. Finally, we provided a review of literature addressing disparities for persons living with both conditions and offered recommendations to reduce disparities for historically marginalized

Acknowledgments

This research was supported by the United States National Institutes of Health -National Heart, Lung, and Blood Institute of the of Health Grant # U01HL142099; National Institute of Minority Health and Development Grant # R01 MD013493 and National Institute of Allergy and Infectious Diseases Grant # P30AI064518. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Statement of conflict of interest

Dr. Longenecker reports research grants Gilead Sciences and served on an advisory board for Esperion Therapeutics. Dr. Meissner reports research support from Viiv Healthcare. The remaining authors declare that they have no conflicts or competing interests.

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    Statement of conflict of interest: see page 147. Dr. Longenecker reports research grants Gilead Sciences and served on an advisory board for Esperion Therapeutics. Dr. Meissner reports research support from Viiv Healthcare. The remaining authors declare that they have no conflicts or competing interests.

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