The big three no.1 Heart disease


In new mini-series, Robert Fieldhouse takes a look at the main threats to our health in the HAART era

People with HIV in the developed world expect to have a near-normal life span, thanks to antiretroviral therapy. But we are still more likely to get sick from cancers or lung, liver or heart disease.
We are at increased risk of heart disease for several reasons.
HIV and its treatment leads to abnormal rises and falls in blood fats that make strokes, heart disease and diabetes more likely.
The DAD study found compelling evidence for a link between HIV and treatment and increased risk of heart disease. This study combined results from several US and European HIV treatment centres and found increased risk of cardiovascular disease for each year spent on antiretroviral therapy.
This sounds scary, as most of us will probably have to take HIV medication for the rest of our lives. But researchers also found traditional risk factors such as smoking, age, gender and elevated blood lipids, were more significant contributors to this increased risk than HIV or its treatment.
Some risks can be reduced easily like stopping smoking. But some, like our age, we are stuck with. So it makes sense to change the things we can.
A downside of a near-normal life expectancy from improved treatments is that we are prone to complications associated with aging like everyone else, and heart disease is one of these.

Right from the start
Any fears about heart disease should not make you delay starting HIV therapy if you need it. Newer combos are more ‘lipid-friendly’ than drugs of old. A large study following people with HIV found no link between starting therapy with a protease inhibitor (PI) or a non-nuke (NNRTI) and heart problems.
The DAD study is still ongoing. As we begin to avoid raised lipids with newer drugs in better combos, and start to use extra meds that reduce elevated lipids, studies like DAD should start to show a decrease in the risk of heart disease.
Don’t get too hung up on the increased risk of heart disease; plenty of studies show antiretroviral therapy means fewer deaths for many reasons. Using some ritonavir boosted PI has been associated with increases in all lipids, especially triglycerides. Among PIs, atazanavir, even when used with ritonavir, appears more lipid-friendly than other boosted PIs.

First-generation nukes
Use of nukes, historically regarded as lipid-neutral, can also affect lipid levels. Clinical trials have shown older nukes such as d4T are more likely to elevate triglycerides than newer drugs.

LDL = low-density lipoprotein cholesterol; HDL = high-density lipoprotein cholesterol; TG = triglycerides; TC total cholesterol

Non-nuke protection
Combos including non-nukes (NNRTIs) like nevirapine or efavirenz are largely considered ‘lipid-neutral’. A majority of people starting therapy see their lipids rise. This may be due to the levels normalising after they have fallen during the months or years of living with a detectable viral load.
People starting with nevirapine (Viramune) typically see larger increases in their ‘protective’ HDL cholesterol levels and larger decreases in their total cholesterol compared with people starting therapy with efavirenz (Sustiva). But the clinical significance of these differences is unknown.
If you are male, older and a smoker (a significant heart disease risk factor) you would be wise to discuss lipid-friendlier drugs with your doctor to minimise risk to your heart. People in the UK typically start therapy with two nukes (NRTIs) and a non-nuke (NNRTI).

Stub it out
Modifying your lifestyle can reduce your risk of developing heart disease or having a heart attack.
Studies show people living with HIV are more likely to be smokers than the general population. Smoking ups your risk of heart disease and is linked to faster HIV disease progression. Stopping will have a greater positive impact on your heart attack risk than taking lipid-lowering pills.

Get active
Several studies show people living with HIV who increase their physical activity can improve their lipids, particularly reducing triglyceride levels. Try swimming, cycling, aerobics, running and weight training (sometimes called resistance training). Alternatively, yoga can help maintain muscle tone and suppleness with the added benefit of its meditative and relaxing qualities.

Tackle your diet
Special diets have not been evaluated methodically in groups of people living with HIV but clinical experience shows the benefits of dieting, as in the general population, tend to be transient and modest.
Research shows combining a healthy diet and regular exercise can lead to metabolic improvements good enough to reduce your risk of heart disease.
In developed countries with access to treatments, people living with HIV are now more likely to become obese than experience wasting. Increased body mass is a contributor to increased lipids, which ups your risk of heart disease.

Hep C co-infection
Recent Canadian research showed people co-infected with HIV and hepatitis C are less likely than people with HIV alone to develop lipid abnormalities during HIV combination therapy. They are also less likely to need lipid-lowering therapy. This benefit is lost if interferon therapy clears the hep C virus.

Switching drugs
A number of published clinical trials show that switching from less lipid-friendly drugs to those with a more favourable lipid profile is safe. But you need to discuss potential risks such as you losing control of your HIV with your doctor.
Modest improvements in ‘bad’ LDL cholesterol and ‘good’ HDL cholesterol and triglycerides can be expected if you switch from a PI to an NNRTI-containing combo. Switching to three nukes (NRTIs) is not recommended as studies question the antiviral potency and durability of this approach.
If you need to stick with PIs, switching within the same class may improve raised lipids. The same applies to some drugs from the nuke (NRTI) class.

Should I take other meds?
Some of us may need additional medications to reduce elevated cholesterol or triglycerides. Over the past few years, many of these have been tested in people living with HIV. See the table below for more information.

Final thought
If you have anxieties about heart disease, ask your doctor for more information about how your risks could be reduced. No one approach is a magic bullet. You’ll probably have to try different strategies to see which you respond to best.

• This article has been supported by an educational grant from Gilead Sciences Ltd

Drugs and supplements

PIs = protease inhibitors; NRTIs = nucleoside reverse transcriptase inhibitors;
NNRTIs = nonnucleoside reverse transcriptase inhibitors; TC = total cholesterol;
HDL = high-density cholesterol; LDL = low-density cholesterol; TG = triglycerides

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