Foundation models enable wearable signal screening for cardiovascular disease among people living with HIV

Abstract Background Cardiovascular disease screening faces significant challenges in resource-limited settings, where infrastructure and computational constraints preclude advanced assessment. These constraints are particularly acute for people living with human immunodeficiency virus (HIV), who experience elevated cardiovascular risk yet often receive care in clinics without specialist diagnostic capacity. Pretrained physiological foundation models offer potential for low-cost screening using wearable sensors, though their applicability in resource-constrained settings remains unclear. Methods We evaluate pretrained physiological embeddings from foundation models for cardiovascular disease detection using photoplethysmography signals from 80 people living with HIV in Ho Chi Minh City, Vietnam. Of 80 participants, 13 (16%) had cardiologist-confirmed cardiovascular disease. We compare strictly zero-shot deployment (NormWear without local training) with frozen PaPaGei embeddings plus locally trained classifier, alongside traditional approaches. Results Here we show that the PaPaGei-embedding approach achieves area under the receiver operating characteristic curve 0.769 (95% confidence interval: 0.70, 0.84) and average precision 0.489 (0.37, 0.61) in this pilot cohort, numerically higher than zero-shot NormWear (0.610; 0.226), principal component analysis features (0.651; 0.208), and supervised clinical models (0.744; 0.433). This approach requires local labels for classifier training but avoids computationally intensive foundation model fine-tuning. However, given the small positive class size (13 cases), these findings require validation in larger cohorts. PaPaGei embeddings capture clinically coherent structure: patients on dolutegravir-based regimens cluster in low-risk regions, while those with high cholesterol variability occupy high-risk areas. Conclusions These preliminary findings provide a potential methodological framework for deploying foundation models in resource-constrained settings, though adequately powered, multi-centre validation is essential before clinical implementation.