Stroke and HIV

A stroke is a serious, life-threatening medical condition. A stroke happens when the blood supply to your brain is interrupted or reduced. This means that your brain can’t get enough oxygen and nutrients, which can cause brain cells to die.

A stroke can be caused by a blocked artery (ischaemic stroke) or the leaking or bursting of a blood vessel (haemorrhagic stroke). The most common type of stroke is an ischaemic stroke.

Some people may only experience a temporary (short-term) disruption of blood flow to their brain. This is called a transient ischemic attack (TIA) or ‘mini-stroke’. TIA symptoms can last between a few minutes and a few hours. A TIA should be treated seriously as it’s a warning sign that you are at risk of having a full stroke in the future.

It is important to call an ambulance quickly if you, or someone around you, have symptoms of a stroke. Early medical care can reduce brain damage and any potential complications.

Your lifestyle and stroke

You can reduce your risk of having a stroke by making changes to your lifestyle. These changes will generally improve your heart health and can help reduce the chance of you developing heart disease. 

• Eat a healthy, balanced diet that contains plenty of fruits, vegetables, and whole grains such as brown rice.
• Eat fewer foods that contain saturated fats, such as butter, cheese, and coconut oil. Instead, replace them with foods that contain unsaturated fats, such as vegetable oils and nuts.  
• Avoid trans fats. Trans fats are usually found in fatty processed foods like takeaways, cakes, and pastries.
• Eat less than 6g of salt a day (about 1 teaspoon). Try to cut down or remove salt when you’re cooking from scratch and check the labels of the foods you’re buying.
• Get regular exercise. Try to aim for 150 minutes of moderate-intensity exercise, such as cycling or brisk walking, each week. If you have very high blood pressure you should speak to a doctor about what type of exercise is safe for you.
• Don’t smoke. If you are a smoker, you can get support to stop smoking from your doctor.
• Limit your intake of alcohol. In the UK, the recommended limit is no more than 14 units a week.
• Limit your use of recreational drugs. Taking cocaine, MDMA (ecstasy), and amphetamines (such as speed) can all increase your blood pressure. Having high blood pressure increases your risk of having a stroke. If you’re concerned about your drug use, speak to your doctor.
• Manage your weight. If you're overweight try to lose weight in a safe and healthy way by eating a healthy balanced diet and getting enough exercise.
• Get enough rest and sleep. Try to get around eight hours of sleep each night. If you’re having trouble sleeping, speak to your doctor.
• Find ways to manage or cope with stress. This might involve exercise, mindfulness, or making time to do the things you enjoy.

If you have already had a stroke, making these lifestyle changes can also help reduce your risk of having another stroke in the future.

Who is at risk?

There are also some things which increase your risk of stroke which you can’t change, including:

• having a close family member who has had a stroke
• having atrial fibrillation (an irregular heartbeat)
• having certain health conditions, such as high blood pressure, diabetes, history of a heart attack and sickle cell disease (SCD).

Women are more likely to have a stroke than men. You’re also more likely to have a stroke as you get older.

Medications that contain oestrogen can also very slightly increase your risk of stroke. These include the combined contraceptive pill, hormone replacement therapy (HRT) taken for menopause, fertility drugs, and gender-affirming hormones taken by some transgender women.

Stroke in people living with HIV

People living with HIV seem to be at an increased risk of having a stroke and have them at a younger age.

One reason for this is thought to be the impact that HIV has on your body. HIV causes chronic inflammation, which is when your immune system has an unhelpful reaction to the virus over a long time. It seems that this inflammation can contribute to the hardening of your arteries which increases your risk of stroke. HIV and opportunistic infections can also cause changes to your blood vessels which may increase your risk of stroke.

Your risk of having a stroke seems to be higher if you have a low CD4 count, or if you have HIV and hepatitis C at the same time.

Some people also develop a condition called immune reconstitution inflammatory syndrome (IRIS) within the first few months of taking anti-HIV medication. You’re more likely to develop IRIS if you have a low CD4 count when you start your treatment. IRIS can affect your brain and increase your risk of having an ischaemic stroke.

Opportunistic infections

Some opportunistic infections can increase your risk of having a stroke, including tuberculosis, meningitis, neurosyphilis and varicella-zoster virus vasculitis. The best way to prevent opportunistic infections is to take your anti-HIV treatment as prescribed.

Anti-HIV medications

Some anti-HIV medications have been linked to an increased risk of stroke. However, the benefits of taking anti-HIV medication far outweigh this risk. The risk of developing stroke will be higher if you don’t take anti-HIV treatment.

Some studies have found that abacavir (Ziagen, also in Kivexa, Epzicom, Triumeq, and Trizivir) is linked to an increased risk of stroke, heart attack and heart disease. It’s not known for sure why this link might exist. You might be told not to take abacavir if you are already at a higher risk of stroke.

One study found that darunavir (Prezista, also in Rezolsta and Symtuza) might increase your risk of heart attack when compared to atazanavir (Reyataz, also in Evotaz). More studies are needed to know if this link exists for sure.

Some anti-HIV medications can also affect your cardiovascular health more generally. More information about this can be found on our page HIV and the heart. Speak to your doctor if you have any concerns.

Symptoms

The most common symptoms of stroke can be remembered with the word FAST: Face Arms Speech Time.

• Face – the person’s face may have dropped on one side; they may not be able to smile, or their mouth or eye may have drooped.
• Arms – the person may not be able to lift both arms and keep them there because of arm weakness or numbness in one arm.
• Speech – their speech may be slurred or garbled, or they may not be able to talk at all despite seeming to be awake.
• Time – it is time to dial for an ambulance immediately if you see any of these signs or symptoms.

Other symptoms can include loss of vision, sudden vertigo (feeling as if the ground is moving or spinning), sudden clumsiness, a very bad headache, and loss of feeling or numbness. If you experience any of these, it’s important to get medical attention very quickly.

The long-term effects of a stroke vary from person to person. Some people make a good recovery. A stroke can cause short-term or long-term disabilities, depending on how long your brain was without blood flow, and which part was affected. Complications may include:

• weakness or paralysis (not being able to move) on one side of your body
• problems talking or swallowing
• memory loss
• difficulty understanding and communicating
• difficulty controlling your emotions
• incontinence (problems controlling your bladder or bowel)
• depression and anxiety.

Diagnosis and monitoring

If you are taken to hospital with stroke symptoms, doctors will carry out a range of different tests. These tests will help them work out if you have had a stroke, and what type of stroke it was. These include:

• a brain scan
• scans of your heart and blood vessels
• a test to see if you can swallow normally
• blood tests to check your cholesterol and blood sugar levels
• checking your pulse for an irregular heartbeat
• taking your blood pressure.

Different treatments are needed for the different types of stroke, so a quick diagnosis is important.

Treatment and management

If you, or someone around you, develops any of the signs or symptoms of a stroke, it is extremely important to call for an ambulance and get emergency treatment immediately.

Some of the best treatments can only be given in the first few hours following a stroke. Seeking medical attention as soon as you can is very important. The treatment you will need depends on the type of stroke you have, including which part of the brain was affected and what caused it.

Once you get to hospital, it’s best if the doctors treating your stroke and your HIV doctors can talk about your health care. For this to happen, you need to give your permission. Doctors specialising in stroke and other diseases affecting the brain, nerves and muscles are called neurologists.

If you’ve had an ischaemic stroke, you will sometimes be given medicine to remove blood clots. This is usually called alteplase and it’s given as an injection soon after you have a stroke. This is sometimes called ‘clot-busting’ medication or ‘thrombolysis’. There shouldn’t be any interaction between clot-busting medication and HIV treatment.

After your emergency treatment, you might be prescribed ‘blood-thinning’ medications. These medications change the way your blood makes clots. There are two types: antiplatelets and anticoagulants.

Antiplatelet medication

Aspirin is an antiplatelet medicine. You will usually be given it as soon as possible after a stroke. Aspirin does not interact with any anti-HIV medications.

Later, you might be prescribed other types of antiplatelet medication. It’s important to know that some of these can interact with anti-HIV treatment. For this reason, you shouldn’t be prescribed clopidogrel (Grepid, Plavix), rivaroxaban (Xarelto) or ticagrelor (Brilique) if you are taking:

• elvitegravir with cobicistat, including in the combination pills Stribild (with cobicistat, tenofovir disoproxil fumarate and emtricitabine) and Genvoya (with cobicistat, tenofovir alafenamide and emtricitabine)
• protease inhibitors such as darunavir (Prezista, also in Rezolsta and Symtuza), atazanavir  (Reyataz, also in Evotaz) and lopinavir (Kaletra) when they are taken with ritonavir (Norvir) or cobicistat (Tybost). You might take a booster separately, or it may be included in a combination pill.

The antiplatelet medicine dipyridamole (Persantin) can be prescribed alongside these medications, but you might need to be monitored more closely.

Prasugrel (Effient) can be prescribed for you no matter what anti-HIV medication you are taking.

Anticoagulant medication

Some anticoagulant pills can interact with the following anti-HIV medications:

• elvitegravir when taken with cobicistat, including in the combination pills Stribild (with cobicistat, tenofovir disoproxil fumarate and emtricitabine) and Genvoya (with cobicistat, tenofovir alafenamide and emtricitabine)

• protease inhibitors such as darunavir (Prezista, also in Rezolsta and Symtuza), atazanavir  (Reyataz, also in Evotaz) and lopinavir (Kaletra) when they are taken with ritonavir (Norvir) or cobicistat (Tybost). You might take a booster separately, or it may be included in a combination pill.

If you’re taking any of these then you should not be prescribed the anticoagulants apixaban (Eliquis) or rivaroxaban (Xarelto). You might also be monitored more closely if you are prescribed edoxaban (Lixiana), dabigatran (Pradaxa), or warfarin.

There is also another anticoagulant called heparin which is given as an injection. Heparin does not interact with any anti-HIV medications.

As well as drugs to prevent and remove blood clots, you may be given medication to reduce blood pressure and reduce your cholesterol levels. There is more information about these medications on our pages High blood pressure and HIV and Cholesterol and HIV.

Surgery

Most people don’t have surgery after having a stroke. However, some people do have operations to reduce complications and help their recovery. If you do have surgery, the type of operation will depend on the type of stroke you had. This can include:

• removing blood from your brain and repairing any burst blood vessels using a craniotomy
• having a shunt fitted, which allows any fluid in your brain to drain away.
• having a thrombectomy, which removes blood clots from your brain.

Rehabilitation

In the weeks and months that follow your stroke, you might go through rehabilitation. Rehabilitation can help you relearn any skills that you lost when you had a stroke. It can also help you learn new skills or ways of coping with any disability. Different types of healthcare professionals can help you with this.

• Physiotherapists can help with balance, posture, and motion.
• Occupational therapists can help you with day-to-day activities.
• Speech and language therapists can help you with communication problems
• Psychologists can help you with emotional and mental health issues.

The amount of time it takes to recover, and the amount of recovery, is different for everyone. It depends on what type of damage was caused by the stroke.

Other sources of information

For more information on stroke, you may find the website of the Stroke Association helpful: www.stroke.org.uk. If you’re in the UK, you can also contact their helpline team on 0303 3033 100.