HIV drugs, and HIV itself, may both make it more likely you could suffer from heart and other cardiovascular problems. Anna Poppa gives some tips on living to a hale and hearty old age
 illustration by john clarkson |
Earlier this year, European doctors reported news that made the headlines in pretty much every HIV journal. Being on HIV drugs for extended periods was linked with a considerably increased risk of having a heart attack. In fact each extra year on treatment raised the risk by 26 per cent.
The study, called DAD, is not the first to look at this issue, and previous ones have not always reached similar conclusions. Even the DAD researchers were quick to point out that when considering the overall risks and benefits of HIV drugs, their findings didn’t outweigh the well-known advantages of taking treatment. Nevertheless everyone agrees this is a problem which we all need to keep an eye on.
The problem is caused by the fact that certain HIV treatments, especially the protease inhibitor drugs (though not only them), are responsible for disrupting the way fats and sugars are processed inside the body. This can result in:
This is a difficult question to answer simply. When Spanish doctors looked recently at how many of their HIV patients developed diabetes after starting HIV treatment, they found a rate of five per cent. Although the condition appeared linked to people’s time on protease inhibitors and was also seen more often in people with lipodystrophy, or with high triglyceride levels. Other risk factors were those more traditionally associated with becoming diabetic such as being overweight or having a family member with diabetes.
HIV itself causes metabolic changes. It actually lowers overall levels of cholesterol in the blood, including the high-density (‘good’) variety that protects against heart disease. Teasing out the contributions made by HIV treatments, and the virus itself, is difficult. Some doctors have argued that a lot of what we are seeing is simply HIV therapy restoring blood fat levels to ones more typical of the population as a whole - which may be, due to the ageing process, higher than pre-HIV levels.
However, a recent study from California found more heart disease in younger men with HIV (meaning up to age 34), and in younger women with HIV (up to 44), than in HIV negative people. Younger HIV positive people were also more likely to get heart disease if they were taking HIV treatments, rather than not.
Heart disease is caused by a range of factors, some of which you can’t change. If you are male, older, and have a history of heart disease in your family, you are already at higher risk. But other risk factors can be changed, such as:
There’s a growing body of evidence that suggests that a number of these ‘modifiable risk factors’ are unusually high in people with HIV. Half of the participants enrolled in the DAD study were smokers. One in 10 had a family history of heart disease; a similar proportion had high blood pressure. High cholesterol affected about seven per cent overall, but this increased substantially in people taking HIV treatments from either of the protease inhibitor or non-nucleoside (NNRTI) classes, more so where people were taking a combination including both.
It is information such as this which has driven the move away from protease inhibitors in people with the option to switch their HIV treatment. Of the currently licensed drugs, the evidence favours a switch to nevirapine or abacavir to reduce blood fats, and perhaps to tenofovir or efavirenz.
Atazanavir is a new protease inhibitor recently licensed in the US, but which is not expected to be approved here until next year. It has not been linked to the blood fat problems which have dogged other drugs in this class, and so could prove a useful additional option.
Smoking is probably the biggest single factor that predisposes people to heart trouble, and is certainly the most important one you can actually do something about. When the Royal Free Hospital in London found a smoking rate of 45 per cent amongst their HIV patients - the UK national average being about 27 per cent - they set up a service to help people quit.
Christine Beveridge tackles smoking cessation as part of her Health Promotion role in the Free’s HIV Department. The service offers advice and nicotine replacement therapy, and Zyban, a pharmaceutical drug which can help people to quit and can be prescribed where appropriate (though it can interact with some HIV drugs). The service has had many successes so far: of 37 people who’ve attended, 16 have stopped smoking four weeks after the date they set to quit.
Christine says the clinic is of most use to those who refer themselves rather than being cajoled by their doctor. “Being ‘prescribed’ quitting smoking is much less likely to be successful,” says Christine. “People can have an unrealistic expectation of what the service can provide. They still need to be motivated to stop and the service can support them, but effort is required on their part.”
David, who was diagnosed with advanced HIV infection ten years ago, has endured many of the adversities of long-term HIV treatment but is very much alive to tell the tale.
Having started treatment in the days of dual therapy, by the late 1990s David had lost a lot of weight, along with a good deal of fat in his legs, arms and feet - hallmarks of lipodystrophy. A four-year bout of diarrhoea was also taking its toll. So by 1998, David switched off the protease inhibitors and d4T, only to discover a new set of problems on efavirenz. “Bad dreams, nightmares, sleep loss all made life very difficult,” says David.
As a 51 year old male smoker of 20 cigarettes a day, and an attendee at one of the larger HIV clinics, I wondered how much David’s medical care had changed, given the greater emphasis on cardiovascular health.
“In 2001 my blood sugar, blood fat and cholesterol were noted as high and I was put on statins [medicine prescribed to reduce blood fats]. Very little was explained and I was never referred to a lipo clinic, even though there is one at the hospital,” recalls David. “As with most things at the clinic, you’re lucky if you see your doctor for 10 minutes every three or four months to get pills and have blood tests. I read stories about people with HIV dying of heart attacks. I just try to do my own research.”
And the cigarettes?
“The only time my doctor asked me about my smoking, he cadged a fag off me!” laughs David. “He does check my chest from time to time and I was very paranoid after a friend died of lung cancer last year; but I can’t drink or take drugs anymore and I hardly have any sex life, so smoking is one of the few pleasures left.”
David is a long-term convert to the gym, having been one of the first people to join the London Central YMCA’s Positive Health Scheme in 1996. “I do two to three sessions each week. The usual kind of programme - cardiovascular exercise for half an hour, stretch for half an hour, and weights for half an hour.”
And David’s partner cooks fresh food every day. “I eat well,” says David. “No takeaways, no frozen food - a balanced and varied diet.”
The longer people survive with HIV, the more we’ll see changes in the kind of health issues which positive people have to deal with. So while David’s future is unpredictable, he knows he still has one: “Given that I lost so many close friends to Aids, I feel blessed that I got it at a time when drugs are available to keep me alive. My viral load has been undetectable since 1998, and my CD4 count is in the six hundreds now. I may be around for a lot longer yet!”
Anna Poppa is a freelance writer and has not had a cigarette for four weeks. annapoppa@tiscali.co.uk
