Depression severity may increase the risk of stroke in people with HIV

Effective HIV treatment (antiretroviral therapy; ART) is increasingly used in Canada and other high-income countries. As the risk of AIDS-related complications is greatly diminished with ART, many people with HIV who take this treatment are living longer. However, as ART users live longer, the risk of aging-related conditions such as cardiovascular disease, diabetes and high blood pressure increases. These conditions can increase the risk of stroke.

Stroke and HIV

Research from the U.S. suggests that, in general, strokes occur at an earlier age in people with HIV, and several studies have found that the risk of stroke is about 20% greater in this population than in people without HIV. Traditional risk factors such as high blood pressure, diabetes and tobacco use tend to be more common among people with HIV compared to people without the virus. However, researchers caution that these risk factors do not explain the entirety of elevated stroke risk among people with HIV. Some researchers say that additional risk factors, including injury to blood vessels and ongoing inflammation (a consequence of chronic HIV), likely play a role in contributing to stroke risk.

Note that although effective HIV treatment greatly reduces chronic inflammation, ART does not eliminate this issue. Therefore, ongoing research on cardiovascular health in people with HIV is needed.

Depression and stroke

Studies in people without HIV have found that depression is associated with an increased risk of stroke.

Research has found that depression is a relatively common condition among people with HIV. Social factors such as stigma and discrimination can contribute to depression risk. As well, proteins produced by HIV-infected cells are likely to contribute to inflammation, which may play a role in the risk of depression.

Researchers have suggested that in people without HIV the following issues play a role in linking stroke and depression:

• elevated blood pressure
• abnormal cholesterol levels
• insufficient physical activity
• persistent stress
• chronic inflammation
• use of stimulants

These factors can play a similar role in people with HIV.

Depression can be a dynamic condition, with symptoms that wax and wane over the course of time. A team of scientists in the U.S. conducted a study to better understand if symptoms of depression contribute to stroke in people with HIV. They analyzed health-related information from five major clinics across the country. These clinics collected information on 13,817 people with HIV between 2010 and 2020. The study team had neurologists investigate reports of new cases of stroke in participants to be certain that strokes did in fact occur. They also looked at data that were collected on symptoms of depression and any relationship to stroke risk. Participants regularly completed a validated survey called PHQ-9 (Patient Health Questionnaire) that asked questions about depression and its symptoms.

Key findings

At the start of the study, 23% of participants were diagnosed with depression. Subsequently, 173 people developed a stroke over an average of seven years. The scientists found that the greater the severity of symptoms of depression, the greater the risk of stroke. Overall, greater severity of depression was associated with a 16% increased risk of stroke.

Additionally, the risk of stroke associated with depression was greater in people younger than 50 years of age compared to older people. There was no differing risk of stroke among depressed people by sex assigned at birth.

Considering many factors, the researchers found that depression severity was independently associated with an increased risk of stroke regardless of “sociodemographic, cardiovascular, HIV and substance use factors […].”

A previous study with U.S. veterans with HIV found that depression appeared to be a risk factor for future development of strokes. In that study, researchers analyzed data collected from 106,333 people (33,528 with HIV and 72,805 without HIV). They found that among veterans with HIV, depression may be a risk factor for strokes, particularly in younger people.

Bear in mind

The present study was not able to uncover precisely why depression severity affected stroke risk. However, the researchers encourage further investigation of how this could happen.

In their report in the journal JAIDS, the scientists made several statements that are of relevance to healthcare providers, such as the following:

“Clinically, our findings should raise awareness among clinicians about possible contributions of depression on stroke risk, especially in people with HIV with more severe depression and younger age, and prompt providers to monitor and address depression in [this population], including specifically in individuals at higher traditional cardiovascular risk.”

They also called for studies “to determine whether medications or other treatment such as behavioral therapy, psychotherapy or antidepressants for depression can reduce stroke risk in people with HIV.”

The present study underscores the importance of addressing issues related to cardiovascular health, including depression.

By Sean R. Hosein

Resource

HIV and cardiovascular disease – CATIE

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