ASANTE protocol targets hidden cardiovascular disease in people with HIV in Nairobi
People living with HIV continue to carry excess cardiovascular risk even when antiretroviral therapy suppresses viral replication. In sub-Saharan Africa, where most people with HIV live, the burden of early vascular and myocardial injury remains poorly characterized. The ASANTE study is designed to fill that gap with a multimodal imaging protocol in Nairobi, Kenya, where investigators will examine whether structural heart and coronary abnormalities are already present before overt cardiovascular disease becomes clinically obvious.
This is a cross-sectional study protocol rather than an outcomes trial, but the clinical ambition is substantial. The investigators plan to evaluate 400 participants at a public hospital in Nairobi, with equal representation of women and people living with HIV. Coronary CT angiography and transthoracic echocardiography form the core of the imaging strategy, creating a paired view of coronary atherosclerosis and myocardial performance. Biological samples will also be banked, including whole blood, peripheral blood mononuclear cells, plasma, and urine, allowing future mechanistic work to extend beyond the imaging readout itself.
Multimodal imaging will define coronary and myocardial phenotypes
The study is centered on two subclinical targets: coronary atherosclerosis and myocardial dysfunction. Coronary CT angiography will be used to define the prevalence of subclinical coronary atherosclerosis, while echocardiography will assess subclinical myocardial dysfunction. In practical terms, this dual approach matters because HIV-associated cardiovascular disease does not present as a single entity. A patient may have early plaque burden in the coronary tree while still maintaining a near-normal clinical exam, or may show impaired ventricular performance before symptoms prompt routine cardiology referral.
A one-dimensional screening approach would miss much of that burden.
By pairing coronary anatomy with cardiac mechanics, ASANTE can capture a more complete phenotype of early cardiovascular injury. That design is especially relevant in settings where ischemic disease, myocardial dysfunction, and systemic inflammation may overlap. Traditional risk scores alone often fail to account for the biology of chronic immune activation, vascular injury, and treatment-era residual risk that accompany HIV infection. Imaging can expose those changes before they announce themselves through angina, heart failure, or an acute coronary syndrome.
HIV and tuberculosis intersect in a setting where residual risk is common
The protocol places unusual emphasis on both traditional and non-traditional cardiovascular risk factors, including endemic infections such as latent tuberculosis. That choice reflects the epidemiology of the region and the possibility that chronic infectious burden contributes to vascular inflammation or myocardial remodeling. In sub-Saharan Africa, HIV and tuberculosis often coexist across a patient’s life course, and the cardiovascular consequences of that intersection remain underdefined. The study does not claim that latent tuberculosis causes coronary disease, but it is built to ask whether these infectious exposures track with measurable structural abnormalities on imaging.
This is where the banked specimens become important. Whole blood, peripheral blood mononuclear cells, plasma, and urine create a platform for later biomarker and immunologic analyses, even though the present protocol does not specify those downstream assays. The infrastructure suggests an intent to connect phenotype with biology rather than treating imaging as an isolated endpoint. For a condition as heterogeneous as HIV-associated cardiovascular disease, that linkage is essential if the field wants to move from description to mechanism.
The population focus is also clinically meaningful. Most cardiovascular imaging evidence in HIV has come from higher-resource settings, while the majority of people living with HIV reside in sub-Saharan Africa. That regional imbalance has left a major gap in understanding how coronary and myocardial disease appears in African patients, where comorbid infection, healthcare access, and baseline risk factors may differ from cohorts studied elsewhere.
A 400-participant cohort aims to establish prevalence, not just association
The planned enrollment of 400 participants gives the study enough scale to estimate the prevalence of imaging-defined disease in this setting, while also evaluating associations with both traditional and non-traditional risk factors. Equal enrollment of women and people living with HIV should help avoid a male-dominant or HIV-skewed sample that limits interpretation. Still, the cross-sectional design defines the limits clearly: ASANTE can map prevalence and correlate exposures, but it cannot prove temporal causality or determine whether infectious exposures preceded the imaging abnormalities.
Even with that limitation, the protocol has bedside relevance. If subclinical coronary atherosclerosis or myocardial dysfunction is common in this cohort, clinicians may need to think earlier about cardiovascular assessment in people with HIV in East Africa. If the burden clusters with specific infectious or metabolic risk factors, future prevention strategies could become more targeted. And if imaging reveals unexpectedly high rates of silent disease, the findings could support more deliberate cardiovascular surveillance in HIV care pathways.
Ethics approval and publication plans place the study on firm footing
Ethical approval has already been granted by the University of Nairobi-Kenyatta National Hospital Ethical Review Committee in Nairobi and by the University of Washington Institutional Review Board in the United States. Results are slated for submission to peer-reviewed journals. The protocol therefore enters the literature as a structured, ethically reviewed effort to characterize a population that has been underrepresented in cardiovascular imaging research.
The biggest unanswered questions remain embedded in the study design itself: how much silent coronary and myocardial disease will be detected, which risk factors will prove most informative, and whether endemic infections such as latent tuberculosis will track with the imaging phenotype. Those answers will not come from the protocol alone, but ASANTE gives the field a coherent framework for measuring them in a region where the burden is likely real and the evidence base has been thin.