HIV Weekly - 30th October 2013

AIDS-related illness and deaths among people in HIV care

Mental health difficulties and drug and alcohol problems are common among people who develop AIDS-defining illness despite being in HIV care, new research shows.

The study was undertaken at the Chelsea and Westminster Hospital, in London, and involved people who received HIV care between 2005 and 2010.

Improvements in treatment and care mean that many people living with HIV now have an excellent life expectancy.

But even in countries like the UK, where there is good access to treatment and free health care, a small but steady number of people continue to develop AIDS-related illnesses or die because of the effects of HIV.

Some people are in this situation because they are diagnosed late, with a very low CD4 count, and are already ill because of HIV when they are diagnosed. Doctors wanted to add to their understanding of the factors associated with an AIDS diagnosis in the modern treatment era, and focused on people who developed a serious AIDS-defining illness six months or more after their HIV diagnosis.

A total of 101 people (out of a possible 6000 whose records were studied) who developed a serious new AIDS-defining condition were identified. Just over half were in long-term HIV care.

Almost all the people who developed AIDS despite not being diagnosed late had been ‘lost to follow-up’ (defined as not attending clinic for four months or more) at some point, at least once. Common reasons included travel abroad and social issues including financial difficulties, housing issues and domestic abuse. Around 59% stopped taking their HIV treatment. Reasons given for this included side-effects, lifestyle, religious views, travel abroad, negative views about the benefits of HIV treatment and belief in alternative therapies.

Mental health problems were very common (35%) among people who developed AIDS despite being in care. Many also had drug (22%), alcohol (24%) and social care (25%) problems.

The authors suggest that HIV care centres should work with local social services to find support for people with social and drug and alcohol problems. Clinics should also offer support with adherence to people in their care who stop taking treatment and work to re-establish contact with people who stop attending appointments.

“Non-attendance and non-compliance in HIV care remain challenges that must be addressed by clinicians to prevent avoidable mortality,” the researchers comment.

HIV and heart attack

A severely damaged immune system is an important risk factor for heart attack in people living with HIV, US researchers report. But people with CD4 cell counts above 500 did not have a higher risk of a heart attack than people without HIV.

Their study found that people with HIV whose lowest-ever (nadir) CD4 cell count was below 200 cells/mm³ were significantly more likely to have a heart attack compared to people of the same age and sex who did not have HIV (a control group).

Cardiovascular disease is now an important cause of serious illness and death in people living with HIV. There’s a lot of debate about the exact reasons, but they seem to include a high prevalence of traditional risk factors such as smoking, the damage that untreated HIV infection can cause and the side-effects of some anti-HIV drugs.

Researchers in the US wanted to see if a low CD4 cell count increased the risk of heart attack.

They therefore compared rates of heart attack between approximately 22,000 people with HIV and 230,000 age- and sex-matched controls.

Overall, the people with HIV were 70% more likely to have a heart attack.

People who had a current or nadir CD4 cell count below 200 cells/mm³ were approximately 75% more likely to have a heart attack than the age- and sex- matched controls.

However, people with a current CD4 cell count above 500 cells/mm³ had a heart attack risk comparable to that seen in the control group.

Traditional risk factors such as older age, being male, smoking, or having diabetes or high cholesterol were also shown to increase the risk of heart attack.

The researchers believe their findings show the importance of early HIV diagnosis and treatment and the “aggressive” management of heart disease risk factors.

Bone health

A study has found a higher prevalence of bone problems among young men with HIV. The authors strongly recommend exercise to counteract loss of bone mass in young people with HIV.

Researchers in Spain found that prevalence of osteopenia (low bone mineral density) and osteoporosis (thinning of bone) was higher in young HIV-positive men aged between 20 and 30 years than in men of the same age who did not have HIV.

Bone problems such as osteopenia and osteoporosis are a recognised complication of HIV, potentially increasing the risk of fractures. The causes appear to include traditional risk factors such as diet and smoking, but also the damage caused by HIV and the side-effects of some anti-HIV drugs, especially tenofovir (Viread, also in the combination pills Truvada, Atripla and Eviplera).

Bone mass reaches a peak in young adulthood. Levels of peak bone mass are associated with the risk of bone problems later in life.

Spanish researchers therefore compared bone mineral density in the spine and hip between 232 people with HIV and 75 HIV-negative age- and sex-matched controls. All were aged between 20 and 30 years. Approximately two-thirds of the people with HIV were gay men and almost all were taking HIV treatment.

Osteoporosis was present in 11% of the people with HIV compared to 4% of the controls. There was also a higher prevalence of osteopenia among the people with HIV (57 vs 51%).

Analysis by gender showed that both osteoporosis and osteopenia were significantly more common among men with HIV than the men in the control group. The prevalence of these conditions did not differ between the women with HIV and HIV-negative women.

A low nadir CD4 cell count and treatment with a protease inhibitor were associated with lower peak bone mass in the hip.

“Considering that this young population will be living with HIV infection for many years, risk factors for osteoporosis should be modified, if possible,” the researchers conclude.

Both exercise and nutrition can play an important role in preventing and addressing bone problems for people with HIV. Talk to someone at your HIV clinic if you have any concerns.