The study, which was published in June 2020 in the Journal of the American Heart Association, followed a cohort of around 700 women, some HIV-positive and the rest HIV-negative, for seven years. During semi-annual follow ups, participants were questioned about “psychosocial risk factors” — depressive symptoms, perceived stress, and post-traumatic stress disorder (PTSD). Then coronary artery plaque was measured via ultrasound. Both sets of women were grouped by high stress and depression versus low stress and depression. Results showed that more than twice as many women living with HIV in the high-stress group had plaque in their arteries, compared with the women who reported low levels of stress. And plaque buildup continued over the years as stress persisted. For the women who were not living with HIV, the prevalence of plaque did not change regardless of high or low reported levels of stress. Plaque in the arteries, known as atherosclerosis, is a key contributor to heart attacks and strokes. People with HIV are at higher risk for atherosclerosis and cardiovascular disease. Previous studies have shown women with HIV are up to 3 times more likely to have heart problems than women without HIV.
Breakdown of Psychosocial Risk Factors
Study participants self-reported whether or not they experienced depressive symptoms, perceived stress, and symptoms of probable PTSD. They were also asked about mental health treatments and psychiatric medication use. Twenty-seven percent of those with HIV and 16 percent of those without HIV reported use of psychiatric medications during the study, but because medication use was not accounted for at several of the follow-up visits, researchers could not determine if there was a relationship between medication use for psychosocial risk factors and the presence of arterial plaque. “In our analysis, we evaluated self-reported depressive symptoms every six months over approximately seven years. We did not define the presence of a diagnosis for depression or compare treated depression to untreated depression,” says Matthew Levy, PhD, a research scientist in the department of epidemiology at the Milken Institute School of Public Health at George Washington University in Washington, DC, and lead study author. “If medication use influenced depressive symptoms, then those decreases in depressive symptoms would have been accounted for in our analysis, based on the nature of how we measured depressive symptoms. Our study did not evaluate whether treatment of depressive symptoms changed atherosclerosis presence or risk. That is an important research question that should be investigated given the findings of this current study.”
Impacts of Race on Plaque Formation
Of the 700 participants, roughly 50 percent were Black, 30 percent were Hispanic, 5 percent were white, and 33 percent were of other or unknown races. While it has been well-documented that Black people are at higher risk of developing coronary artery disease, previous studies have not found a correlation between HIV status, race, and plaque formation. “Although we did not report on atherosclerosis by race or ethnicity in our recent paper, this has previously been reported in the primary publication of this cardiovascular sub-study of the Women’s Interagency HIV Study (WIHS),” explains Dr. Levy. “In that prior analysis, after adjusting for HIV status, study site, socio-demographics, behavioral factors, and cardiometabolic factors, there was no difference in the formation of new carotid artery plaque among women with different races or ethnicities.”
Why Are Depression and Stress Risk Factors for Atherosclerosis?
Research has shown that depression and stress can cause an inflammatory response in the body. Stress causes the fight-or-flight response to kick in, which results in a cascade of hormones flooding the body. When stress is short-lived, the body has time to return to a state of equilibrium, but with chronic stress, the body does not reset and stress hormones remain in the system, resulting in an inflammatory response. A chronic state of inflammation has been indicated as an underlying cause of heart disease. “Based on research in the general population, depression is known to contribute to inflammation and endothelial dysfunction, which are contributors of atherosclerosis, although these biological pathways are not yet fully understood,” says Levy. “Also, people with depressive symptoms are more likely to have chronic stress, and vice versa, and there are known effects of chronic stress on risk of atherosclerosis.” And although causes of stress and depression were not documented in this study, Levy said there are many contributing factors for study participants. “Women living with HIV often experience intersecting social-structural vulnerabilities related to belonging to multiple marginalized groups such as being female, Black, Hispanic, HIV-positive, and of low socioeconomic status,” he explains. “Such social-structural factors can converge among women living with HIV to cause stress directly as well as indirectly through increased vulnerability to other life stressors. Studies have reported a high prevalence of intimate partner violence, sexual violence, and physical violence among women living with HIV.” RELATED: Many Domestic Violence Survivors Have Undiagnosed Brain Injuries Similarly, stress among Black women can be caused by a myriad of societal factors, like discrimination attributed to racism and sexism, [which] is common and associated with elevated stress. For those with a positive HIV diagnosis, the stresses surrounding the disease itself can also contribute to the overall perception of stress and depressive symptoms. “There are also possible stressors related to one’s HIV status, both directly (managing one’s HIV diagnosis, adhering to medications, side effects) and indirectly (stigma, emotional challenges),” says Levy. More research is needed to fully understand the link between psychosocial impacts and coronary artery disease and HIV status.
