Early Structural Cardiovascular Disease, HIV, and Tuberculosis in East Africa (ASANTE): Cross-sectional study protocol for a multimodal cardiac imaging study in Nairobi, Kenya.

Abstract

Introduction: Persons living with HIV (PLWH) have an augmented risk of cardiovascular disease, including atherosclerosis and myocardial dysfunction, despite effective viral suppression with antiretroviral therapy (ART). Despite the majority of PLWH residing in sub-Saharan Africa, there are limited reports from the region on structural cardiovascular changes due to this residual risk.Methods and analysisThe Early Structural Cardiovascular Disease, HIV, and Tuberculosis (ASANTE) cross-sectional study will be conducted in a public hospital in Nairobi, Kenya. It will enroll 400 participants (50% female, 50% PLWH) to undergo comprehensive cardiovascular phenotyping using multimodal imaging (coronary CT angiography [CCTA], echocardiography) and banking of biological samples (whole blood, peripheral blood mononuclear cells, serum, and urine). We will define the prevalence of subclinical coronary atherosclerosis by coronary CT angiography (CCTA) and subclinical myocardial dysfunction by transthoracic echocardiography, and evaluate both traditional and non-traditional risk factors, including endemic infections such as latent tuberculosis. This study will contribute important data on phenotypes of and risk factors for HIV-associated cardiovascular disease in this under-studied region.Ethics and disseminationEthical approval for the ASANTE study was granted by the University of Nairobi-Kenyatta National Hospital Ethical Review Committee, Nairobi, Kenya. Results will be submitted for publication in peer-reviewed journals.

Key messages: What is already known on this topic: In studies from high-income countries, HIV infection is an independent risk factor for structural cardiovascular abnormalities (atherosclerosis, myocardial remodeling) and corresponding incident cardiovascular events.Emerging data from sub-Saharan Africa suggest there may be a unique epidemiological profile, in which HIV and traditional cardiometabolic risk factors (e.g., hypertension, diabetes, overweight/obesity, smoking) are not associated with coronary atherosclerosis.Unique endemic risk factors for cardiovascular disease in HIV have yet to be defined in sub-Saharan Africa.What this study adds: We will define the prevalence of and risk factors for subclinical coronary atherosclerosis and myocardial disease in a cohort of Kenyan adults with and without HIV who have been enriched for cardiometabolic risk factors using multimodal imaging (coronary CT angiography, speckle tracking echocardiography).We will assess the contribution of latent tuberculosis infection as a potential endemic risk factor for subclinical cardiovascular abnormalities identified on multimodal imaging.How this study might affect research, practice, or policy: Delineating the burden, phenotypes, and unique risk factors for early cardiovascular disease in this setting will facilitate tailored interventions for screening, monitoring, and management among persons with HIV.Developing multimodal cardiac imaging infrastructure in this resource-limited setting will expand tools for understanding the natural history of cardiovascular disease among persons with HIV in this unique setting.This study will yield a diverse collection of stored biological samples, including peripheral blood mononuclear cells, plasma, whole blood RNA, and urine. In combination with the cardiac imaging repository, this biobank will facilitate future collaborative efforts to identify mechanisms underlying phenotypes of cardiovascular disease in this population.