HIV update - 21st June 2017

Broken bones

Fractures (broken bones) can occur more easily when bones are weakened. Bones lose their strength and resilience with age because bones become less dense. This process is called osteoporosis. Women are more likely to develop osteoporosis than men, especially after the menopause. People who have a sedentary lifestyle, have a poor diet, who drink excess alcohol or who smoke are at greater risk.

Rates of osteopenia (low bone mineral density) and osteoporosis are higher in people living with HIV than in the general population. It’s possible that HIV itself or the body’s response to HIV may contribute to bone problems. In addition, many people living with HIV smoke, drink, don’t get enough exercise or have other risk factors for bone problems. In addition, some anti-HIV medications can have an impact on the bones, especially in the first year of treatment.

A recently published study from the United States shows that broken bones increase in frequency a full decade earlier in HIV-positive men compared to their HIV-negative peers. The study found that the fracture rate among men in their 50s was double that observed in HIV-negative men in the same age range (the control group).

Guidelines from the British HIV Association recommend that, in people living with HIV, everyone over the age of 50 and all women who have gone through the menopause should be assessed every three years for their risk of having a fracture. This involves taking information on your age, weight, lifestyle and medical history.

If you have low bone density or osteoporosis the following changes may help reduce the risk of fractures:

• Exercise regularly.
• Don’t smoke.
• Drink less alcohol.
• Get enough calcium and vitamin D.
• Consider hormone replacement therapy after the menopause.
• Consider whether a change of HIV drugs will help.

See NAM’s factsheet 'Bone problems and HIV' for further information.

Cognitive impairment

You might have noticed changes such as a shorter attention span, slowness in processing information, less fluency in the use of language, a reduced ability to plan and organise everyday life, or lapses in memory. Most people in their 50s, 60s and 70s begin to notice some lapses in memory or slower thinking. These changes are a normal part of getting older. But if someone has more of these difficulties than other people of the same age, this may be described as cognitive impairment.

Cognitive impairment has many causes. HIV infection may cause some changes, but blocked arteries, heavy alcohol consumption, depression and anxiety and Alzheimer’s disease are probably the bigger culprits.

Being able to predict who might be at risk of cognitive impairment would be useful if it permits changes in lifestyle or health care to minimise the impairment.

A Canadian study has looked at risk factors for cognitive impairment in a group of 191 people living with HIV who were followed for three years. Everyone in the study had a fully suppressed viral load and underwent a battery of tests every six months to check their cognitive function.

The study found that impaired kidney function was the strongest predictor of cognitive impairment. Living with diagnosed HIV infection for more than 15 years, having 12 years or less of education, and high levels of protein in the cerebrospinal fluid were also risk factors. Having more of these risk factors increased the risk; having none of these risk factors was associated with a very low risk of developing cognitive impairment.

The study investigators say that providing information on the future risk of cognitive impairment may help people make lifestyle changes.

Lifestyle changes such as a diet high in whole grains, fruit and vegetables, regular exercise, low alcohol intake, stopping smoking and keeping your weight in a healthy range may result in improved cognitive function, but more research is needed on this topic in people living with HIV.

A European study also published this month shows that when cognitive impairment is suspected as a result of difficulties in managing everyday tasks, it is important to consider whether depression, anxiety or other medical conditions might be contributing to the problem.

“Failure to recognise these important elements of patients’ lived experiences risks diagnostic delay, failure to address important needs, unnecessary investigations and further anxiety,” the researchers comment.

The study looked at people living with HIV in five European countries. It assessed their ability to carry out everyday tasks such as housekeeping, work, watching television and social activities, and self-reported symptoms of cognitive impairment such as difficulties in problem solving, sustaining attention or concentration, or forgetfulness. Cognitive performance was also assessed by tests.

The study found that although there was an association between self-reported cognitive problems, worse performance on cognitive tests and difficulties in everyday functioning, there were also strong associations between difficulties in everyday functioning and depression, anxiety, financial difficulties, unemployment, and longer time since HIV diagnosis.

The researchers say that more work is needed to test whether interventions to treat depression and anxiety and to relieve other problems also have an effect on cognitive function.

If you are experiencing problems with depression or anxiety and problems in everyday activities, help is available through your HIV clinic or through your GP.

See NAM’s factsheet 'Cognitive impairment and HIV' for further information.

Hepatitis C treatment

New direct-acting antiviral (DAA) treatments eliminate the hepatitis C virus after a short course of treatment in over 90% of people who take them, although cure rates can be slightly lower in people with very advanced liver disease. Curing hepatitis C should reduce the risk of further liver damage, liver cancer and other conditions caused by hepatitis C infection.

However, a review of all clinical trials of these drugs has concluded that there is no evidence that DAA treatment reduces the risk of illness or death in people who receive it.

The review was carried out by a respected international research group, the Cochrane Collaboration, but liver experts say that the study is deeply flawed. The findings have also been strongly criticised by patient advocacy groups.

In particular, liver experts point out that none of the studies lasted long enough to measure whether treatment reduced the risk of illness or death. On average, studies included in the review lasted 34 weeks.

The reason why the studies lasted an average of 34 weeks was because the question of whether curing hepatitis C results in an improvement or stabilisation in liver disease has already been settled. Liver experts have long accepted that a sustained virologic response to treatment – no detectable virus 12 weeks after completing treatment – means that the virus is eliminated. If hepatitis C virus is no longer present, the agent causing liver damage is gone, and the liver can begin to stabilise or heal in people without very advanced disease.

A large review of studies of people treated with pegylated interferon and ribavirin – the previous form of treatment for hepatitis C – shows that people cured of hepatitis C are less likely to die than those who are not cured by treatment.

Longer-term follow-up of people treated with DAAs is still taking place but at this stage there is no reason to think that curing hepatitis C with DAAs will not result in a similar reduction in the risk of illness or death.