SYSTEMATIC REVIEW article
Front. Cardiovasc. Med.
Sec. Cardiovascular Epidemiology and Prevention
Volume 12 - 2025 | doi: 10.3389/fcvm.2025.1586019
Characterization and Risk Stratification of Coronary Artery Disease in People Living with HIV: A Global systematic review
Provisionally accepted
- 1University of Pretoria, Pretoria, South Africa
- 2Durban University of Technology, Durban, South Africa
- 3David Umahi Federal University of Health Sciences, Nsukka, Nigeria
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Background: Coronary artery disease (CAD) is a leading cause of mortality among people living with HIV (PLWH). Risk stratification remains inconsistent due to geographic disparities, ART-related metabolic effects, and overreliance on strength of association. This review synthesizes global evidence to classify CAD risk factors in PLWH, aiming to improve predictive models and preventative strategies. Methods: Following the PRISMA 2020 guidelines, a systematic review was conducted across six databases: PubMed, Scopus, Web of Science, Medline, CINAHL, and African Journals (SABINET). Two independent reviewers screened studies and extracted data. Narrative synthesis and metaanalysis were conducted. Risk factors were classified using Rw, causality index (CI), and public health priority (PHP). Findings: Twenty-two studies involving 103,370 participants were included. First-class risk factors (CI: 7-10) included hypertension (OR: 4.9; p <0.05; Rw: 4.5), advanced age (≥50 years) (OR: 4.96, p <0.05, Rw: 3.58), dyslipidemia (OR: 2.15, p <0.04, Rw: 2.15), and overweight/obesity (OR: 1.81, p <0.05, Rw: 1.36). Second-class risk factors (CI:5-6) included family history of CVD (OR: 3.25, p < 0.05; Rw: 2. 24). Third-class risk factors (CI ≤4) included diabetes (OR: 2.64, p <0.05, Rw: 1.32), antiretroviral therapy exposure (OR: 1.68, p <0.05, Rw: 0.63), and homosexuality (OR: 1.82, p <0.05, Rw: 0.62). Critical thresholds (cumulative Rw: 14.8 and 8.0) were set at 75th and 50th percentiles of cumulative Rw. At GTT value of 0.50, the parsimonious global clinical prediction model for HIV-related CAD included age, hypertension, dyslipidemia, family history of CVD, diabetes, and overweight/obesity (Rw: 15.5, GTT: 4.05). For primary prevention, the optimal model comprised hypertension, dyslipidemia, and obesity (Rw: 8.01, GTT: 2.07). Advanced age and hypertension were "necessary causes" of CAD among PLWH. Conclusion: Association strength alone cannot determine CAD risk. Cumulative risk indexing and responsiveness provide a robust framework. Prevention should prioritize hypertension and dyslipidemia management, with interventions for obesity, smoking, and virological failure. Age and hypertension should prompt cardiovascular screening. Standardized risk definitions, accounting for the role of protective factors and integrating evidence with domain knowledge are vital for improved CAD risk stratification and prediction in PLWH. Routine cardiovascular screening in HIV care remains essential.Registration: PROSPERO ID: CRD42024524494.
Keywords: Coronary Artery Disease, HIV, risk stratification, Epidemiological model, Systematic review
Received: 13 Mar 2025; Accepted: 27 Jul 2025.
Copyright: © 2025 Martins, Pillay, Ibeneme and Mshunqane. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Nweke Martins, University of Pretoria, Pretoria, South Africa
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