Impact of alcohol on heart disease in people with HIV - HIV update, 12 February 2024

Impact of alcohol on heart disease in people with HIV

People living with HIV have a higher risk of cardiovascular disease, for example heart attacks, strokes and heart failure, compared to people without HIV. But we don’t yet know how much modifiable risk factors, like smoking, poorly controlled blood pressure or alcohol, affect this risk of cardiovascular disease. How much impact would improving management of these risk factors have on cardiovascular disease in people with HIV?

Researchers investigated this by looking at 227,600 people without HIV and 8285 people with HIV in San Francisco and northern California.

The researchers found people with HIV had an 18% higher risk of a heart disease, like a heart attack or stroke, compared to people without HIV. They also looked at how well conditions such as high blood pressure, high cholesterol or diabetes were managed. The results showed that blood pressure and cholesterol were similarly well managed in people with HIV and people without HIV. But on average, people with HIV had more poorly controlled blood fats and better controlled diabetes than people without HIV.

When their cholesterol, blood fats and diabetes were well managed, people with HIV and people without HIV had the same risk for cardiovascular diseases. But people living with HIV and previously diagnosed high blood pressure had a higher risk of cardiovascular disease, even if their high blood pressure was well managed.

The results show that, overall, having HIV contributes much less to the risk of cardiovascular disease than high blood pressure, high cholesterol or uncontrolled diabetes.

But the study did find that HIV increased the impact of one risk factor in particular – unhealthy alcohol use. People with HIV who frequently binge drink were twice as likely as people without HIV to experience a heart attack, stroke or heart failure. Binge drinking means drinking 8 to 10 UK units of alcohol in one day – that’s the same amount of alcohol as in one bottle of wine.

“These findings suggest that alcohol use may be particularly harmful for people with HIV,” the researchers conclude. Moderate drinking or only sometimes drinking a lot did not increase the risk of cardiovascular disease. That means people living with HIV do not have to cut out alcohol altogether to reduce the risk for cardiovascular diseases, but may reduce the risk by cutting down their alcohol intake.

Unnecessary medication for older people with HIV

Growing older with HIV may mean that you’re more likely to take multiple different medications. But taking different medications together can sometimes change how well they work and what side effects they have, especially in older people. What’s less clear is how many older people with HIV are affected by this and what proportion are taking medications they don’t need, or which are potentially harmful.

Researchers in Spain carried out a review of 39 studies that looked at inappropriate prescription in older people with HIV. Many studies identified by the review looked at the burden of anticholinergic drugs. Anticholinergic drugs are used to treat conditions that occur more frequently in older people, including stomach ulcers, chronic obstructive pulmonary disease (COPD), over-active bladder, cystitis and insomnia. They include certain types of antidepressants, some antihistamines, antipsychotics, antiepileptics and some painkillers.

Anticholinergic drugs can sometimes have harmful effects on older people, for example neurocognitive impairment and falls. Additionally, the use of multiple drugs can lead to anticholinergic syndrome, in which people develop confusion, agitation and restlessness and may lose balance and co-ordination. The review showed that around 25-30% of older people with HIV were taking anticholinergic drugs.

The most frequently over-prescribed drugs identified in this review were benzodiazepines, such as lorazepam and diazepam. They’re often prescribed for anxiety and as short-term sleep aids. The researchers say clinicians need to be careful in the way they prescribe these drugs (for example, benzodiazepines should only be prescribed for short periods).

On the other hand, the review also found that doctors were failing to prescribe statins to prevent cardiovascular disease, and vitamin D and calcium to protect against bone thinning and fractures.

The review also looked at studies investigating so-called ‘medication reviews’. During these reviews, you and your doctor or pharmacist look at medications you currently take to see if anything needs to be changed. The studies found a medication review can help with medication-related problems and with cutting out unnecessary medications.

The authors of the review highlight that medication reviews using standardised tools can help check whether a prescribed medication is appropriate for someone and flag gaps in prescribing. These tools may need to be adapted for people with HIV.

In the United Kingdom, it’s recommended that people with long-term conditions, like HIV, and people taking multiple medications have regular medication reviews. This could be done by the pharmacist at your HIV clinic, your community pharmacist, or one of your doctors.

COVID-19 and gut health

Bacteria in our gut influence how our immune system reacts to infections. Gut bacteria can also promote or switch off inflammation, which is an important part of the immune system’s response to injury or infection. But persistent, ongoing inflammation can increase the risk of developing other illnesses and conditions and may be connected to more severe COVID-19 outcomes.

Researchers are interested in the link between gut bacteria and COVID-19. They are investigating if bacteria in the gut influence how severe someone’s COVID-19 gets and how long their symptoms last. Some small studies in people without HIV have shown that people with more severe COVID-19 and long COVID had fewer of the bacteria that promote helpful immune responses.

Researchers in Japan looked into the relationship between gut bacteria and COVID-19 severity in people living with HIV. They found that people with HIV with COVID-19 showed less of a type of bacteria that has anti-inflammatory effects, both when they were admitted to hospital and for up to a month afterwards. People with moderate or severe COVID-19 also had slower recovery of this type of helpful bacteria after admission to hospital.

Two people with HIV in the study experienced long COVID. The researchers found that both people had less diverse gut bacteria up to a year after they initially got COVID-19.

The researchers say that the results are tentative and need to be confirmed in larger studies. But they think that researching gut bacteria is a promising avenue for understanding COVID-19 and managing severe COVID-19 and long COVID.

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