Most of the items in this edition of HIV Weekly are about the possible side-effects of HIV treatment.
All drugs can cause side-effects. Most of the side-effects caused by the antiretroviral drugs (ARVs) used in treating HIV are mild and lessen or go away completely over time. But some others can be more serious, or can cause problems in the longer term.
There are now more than 20 anti-HIV drugs available. Researchers are trying to find out more about the causes of side-effects and how they can be avoided or treated.
It’s usually possible to do something about side-effects. You don’t have to grin and bear them. It's important to talk to your healthcare team about any side-effects, particularly to avoid the possibility of serious or longer-term problems.
For more information you may find the NAM booklet Side-effects helpful. It is available free to people with HIV in the UK, as well as on our website and through clinics and organisations in the UK.
You can also read about side-effects on namlife.org, NAM’s mini-site for people with HIV.
HIV treatment and heart attack risk
A big international study has found that four anti-HIV drugs may increase the risk of heart attack.
The drugs are the nucleoside reverse transcriptase inhibitors (NRTIs) abacavir (Ziagen, also in the combination pills Kivexa and Trizivir ) and ddI (didadosine, Videx), as well as the protease inhibitors Kaletra (lopinavir/ritonavir) and indinavir (Crixivan).
The study found that patients taking abacavir had their risk of heart attack increased by 70%, and those taking ddI had a 30% increase in risk.
Each year of treatment with abacavir also increased the risk of heart attack by 7%. Similarly, the risk of heart attack increased by 13% with each year of treatment with Kaletra and by 12% for every year of treatment with indinavir.
These figures are concerning, but they are not a cause for panic. The risk of heart attack associated with each drug is very small when compared to traditional risk factors such as high blood lipids, diabetes and smoking.
And there have been other studies that have not shown an increased risk of heart attack connected with these drugs, so the exact effect of the drugs themselves is not yet certain.
In addition, untreated HIV has been associated with an increased risk of heart attack. This is one of the reasons why it’s recommended to start HIV treatment before the virus has done too much damage to the immune system. It’s especially important for people with risk factors for heart disease to start HIV treatment when their CD4 cell count is around 350.
But the results of this study will help doctors and patients make informed choices about the best combination of anti-HIV drugs for them.
In the UK, for example, abacavir is not recommended for people with other risk factors for heart attack.
If you are worried about HIV treatment and your risk of heart disease, then it makes good sense to talk to your HIV doctor about your treatment options.
It’s also good to know that there’s a lot you can do to reduce your risk of heart disease. Good nutrition, exercising and stopping smoking can all make a big difference.
HIV treatment and kidney side-effects
US researchers have found that treatment with tenofovir (Viread, also in the combination pills Truvada and Atripla ) may increase the risk of kidney disease.
Tenofovir is a widely-used anti-HIV drug and is recommended for people starting HIV treatment.
It’s easy to take, and is generally very safe. But there is some concern that it may cause kidney damage.
Research studies exploring the relationship between tenofovir and kidney problems have produced conflicting results. Although some did find that the drug could cause this side-effect, other research found that traditional risk factors for kidney disease and untreated HIV were much more important.
But now a two-year American study involving over 1000 people has found that people taking tenofovir are more likely to experience kidney problems than those taking other anti-HIV drugs. They looked at three important measures of kidney function and all were worse in people taking tenofovir.
The researchers therefore recommend that tenofovir should be used “strategically”. This means that its use should be avoided if a person has other risk factors for kidney disease, for example diabetes.
It’s also important to note that HIV itself can cause kidney problems and early HIV treatment is recommended for people with risk factors for kidney disease.
Routine HIV care will involve kidney function tests and the results of these help doctors and patients make treatment choices.
HIV and the bones
HIV can cause a loss of bone. This problem may also be a side-effect of some anti-HIV drugs.
Low bone mineral density is often seen in women who have reached the menopause. Older women therefore have an increased risk of fractures.
Now researchers have found that post-menopausal women with HIV may have a high risk of fractures because of low bone density.
The research involved over 100 post-menopausal women with HIV who were of Hispanic or African American ethnicity. Their bone density and risk of fracture was compared to post-menopausal HIV-negative women of the same ethnicities.
The women with HIV had lower bone density in the neck, spine and hip. The researchers expressed concern that this could mean that they have a higher risk of fractures.
Earlier French research found that people with HIV did not have an increased risk of fractures but this did not look exclusively at women.
Routine HIV care should involve regular tests to assess the health of the bones. A number of effective treatment options are available if a problem is identified.
Screening for anal cancer
Rates of anal cancer are higher in people with HIV than in the general population. Especially high rates are seen in HIV-positive gay men.
Certain strains of the human papillomavirus (HPV) can cause cell changes in the anus that can lead to cancer. If identified, these cell changes can be effectively treated.
But there’s disagreement about the best way to screen people with HIV for anal cancer.
Researchers therefore wanted to see if tests similar to those used to check for cervical cancer could accurately detect pre-cancerous cell changes in the anus.
Unlike other screening methods, this test is easy to perform and doesn’t cause too much discomfort.
The researchers found that the test (often called a ‘smear’) identified most of the pre-cancerous cell changes diagnosed by biopsy or high resolution anoscopy.
The tests worked especially well in people with HIV who had CD4 cell counts below 400. The researchers therefore think it could be a useful screening tool for people who have their HIV diagnosed late.
The accuracy of anal smear tests was similar to that of cervical smears. The researchers therefore recommend that anal screening should be used along with existing screening methods to enable the early diagnosis of pre-cancerous cell changes.
For more information on health monitoring you may find the NAM booklet CD4, viral load and other tests helpful. It is available free to people with HIV in the UK, as well as on our website and through clinics and organisations in the UK.