Perspective:

Many prospective randomized trials have defined the benefits of various anti-HTN classes for patients requiring initial and secondary management. However, these trials have not included large volumes of patients with HIV being actively treated with anti-retroviral therapy. Anti-retroviral therapy and comorbid infections (e.g., hepatitis C) have the potential to accelerate kidney disease; alter fat, insulin, and salt metabolism; and induce vascular dysfunction in patients with HIV. These results largely confirm the findings from the ALLHAT trial, but focus on patients with HIV. In particular, there seems to be similar risk of incident CVD among patients treated initially with ACEi/ARB, diuretics, or CCBs. Interestingly, initial use of a beta-blocker was associated with an increased risk of CVD.

While the use of propensity score matching minimizes baseline differences and measured confounders, it is possible the unmeasured confounding baseline differences could contribute to this outcome. This is especially true since beta-blocker therapy is generally not considered a first-line treatment for HTN. The association between ACEi/ARB use and lower risk of heart failure in patients without CKD may be attributed to the anti-inflammatory, renal-protective, and improved endothelial properties of ACEi/ARB therapy. Although these findings come from retrospective data, they largely align with the findings from the ALLHAT and other randomized trials. Therefore, clinicians who manage patients with HIV and HTN should consider using ACEi/ARB therapy as the first-choice therapy for most patients.