A review on the disease risk and contemporary management of PAD in the HIV population.

INTRODUCTION: The development of highly active antiretroviral therapy (HAART) for patients with Human immunodeficiency virus (HIV) has improved life expectancy resulting in increased longevity. Consequently, the prevalence of peripheral arterial disease (PAD) in this population has continued to rise while HAART has been shown to be an independent risk factor for the development of accelerated atherosclerosis complicating management strategies. The aim of this study was to investigate the literature for trends and contemporary outcomes of lower extremity revascularization among patients with HIV and PAD. METHODS: A review of full text articles evaluating PAD outcomes in patients with HIV from inception to 2024 was performed. Methodological quality of all included studies was assessed using the Newcastle-Ottawa Scale. A pooled analysis of interventions and outcomes was performed from available studies. RESULTS: Ten studies were included for analysis. Methodological quality ranged from high variability and poor-to-good quality. HIV positive patients were 34% more likely to undergo an open surgical bypass (OR 1.34 (95%CI 0.84-2.13, p<0.001)) and more likely to undergo amputation (OR 1.72 95%CI 0.91-3.80, p <0.001). They were 4% less likely to suffer a mortality while hospitalized (OR 0.96 (95%CI 0.54-1.71, p<0.001)). DISCUSSION: Contemporary management of PAD in the HIV population has demonstrated improvements in understanding disease pathophysiology, including the impact HAART medications have on PAD development and determining which patients would benefit from intervention. While patients with HIV and PAD tend to be younger, they are more likely to undergo an open surgical bypass or primary in-hospital major amputation resulting in longer hospitalization and higher cost burden. Lower extremity revascularization in this population appears to be safe with acceptable patient related outcomes, particularly in the asymptomatic with low viral loads and acceptable CD4 counts. The small number of retrospective studies, high heterogeneity, and lack of patient-specific factors were noteworthy limitations. CONCLUSION: PAD prevalence in HIV patients is growing, compounded by longer life expectancy with HAART medications. Lower extremity revascularization has demonstrated important utility to benefit patients with PAD and HIV with a wide range of influence. Further studies are needed to assess long-term outcomes after revascularization.