Positive Life NSW

HIV virus

For many years if you were a person with HIV and had any unexplained symptom it was ‘just the virus’. The focus was solely on anti-viral treatments and medical conferences on HIV were dominated by anti-HIV drug therapy.

The 17th Conference on Retroviruses and Opportunistic Infections (CROI) was held in San Francisco in mid February and there are fantastic podcasts available online, so I was able to watch a lot of the conference at home. After some hours of watching, the overwhelming picture I got about HIV medical care is that ‘it’s not just about the virus anymore’ nor are HIV anti-viral drugs the only game in town. The landscape in HIV medical care has changed immensely and this has important consequences for people with HIV and the way medical services need to be organised in the future.

Living longer with HIV

HIV has now become a chronic manageable illness (some people even say treatable, but I dispute this). Two European studies1–2 showed that people with HIV who get infected now can expect very close to a ‘normal’ life expectancy. But for me, the important phrase is ‘chronic illness’.

Living long term with HIV is associated with increased risk of a whole set of other conditions typically associated with getting older. So this conference – like any HIV medical conference in the future – was not just about ‘HIV disease’, it was also about heart disease, bone disease, hepatitis C, liver disease, diabetes and metabolic syndrome, cancers, kidney disease and neurological disease. In fact, it’s hard to think of any organ system which doesn’t have some disease that is associated with living long term with HIV.

The causes of the increased risk of these various organ system diseases vary. They are usually described as being due to a mix of:

• the long-term effects of the drugs used to treat HIV
• lifestyle factors (with smoking being the bete noir of bad lifestyle choices)
• genetic factors
• HIV itself or the chronic inflammation caused by HIV.

As more research gets done in more and more of these associated diseases, it is being shown that HIV infection itself is an independent risk factor for the increased risk of most of these diseases. This belies the notion that HIV has become ‘treatable’.

Despite treatments, small amounts of HIV remain and the immune system is sometimes described as being in a state of constant stimulation with constant elevated levels of some inflammatory hormones. These hormones have been shown to be associated with a number of conditions, including ageing itself (this isn’t a ‘condition’ even though it is often described as a medical disorder).

Lifestyle matters

What is also emerging loud and clear is that ‘lifestyle matters’. For example, HIV was independently shown to increase the risk of lung cancer. But the increased risk is miniscule when compared to the increased risk due to smoking.

There were a lot of presentations on cancer at CROI. I usually bypass these. After all, cancer is scary and used to be very hard to treat in people with HIV, but that picture is changing and now cancer is often very treatable in people with HIV. For ages we’ve known that the incidence of many cancers is much higher in people with HIV. While HIV is an independent risk factor for many cancers, what emerged at CROI in a few presentations is that when you control for lifestyle factors, the difference in risk due to HIV may be much smaller than originally estimated. It is known that populations of people with HIV tend to have increased lifestyle risk factors for many cancers. So the increased incidence that has been observed is more due to lifestyle than HIV itself.

The priority being given to lifestyle factors made me reflect on the historical attitudes people with HIV have towards ‘healthy living’. Before treatments, I remember my group of positive friends who mostly all smoked and did party drugs. Our negative friends often tut tutted in dismay thinking we had more reasons to look after themselves than they did. For my group of positive friends, they had it wrong – if you had what was then considered an inevitably fatal illness, then pleasure was more of a priority than health.

As treatments arrived, ‘healthy living’ took on a different dimension. There’s always been a balance between pleasure and health – and this piece is not to herald in some new era of ‘healthy living’ sermons. At a healthy living workshop I well remember a positive person saying something like ‘I don’t live just to be healthy, I live for pleasure and it helps to be healthy’. That’s all well and good, but now if you are a person with HIV you will probably spend a number of years living over 50 at increased risk of a number of medical conditions. For almost every one of these conditions, lifestlye factors matter – and sometimes it matters a lot.

Indeed, attention to lifestyle factors and stopping smoking are now probably more important for health than anti-HIV drugs in some instances. This is the changing face of HIV medical care. So many of these HIV-related conditions are preventable, they are very common and they now characterise living with HIV long term.

When you are over 50 and you go to your doctor now – HIV-drug treatment often takes up a tiny percentage of your consultation. And if you’re a younger person with HIV, then maybe the old habits of using HIV as a rationale for having a good time need to be balanced with the consequences of lifestyle factors in HIV-related medical conditions.

As communities of people affected by HIV, we have often done huge amounts of work to prevent further HIV infections. These same communities tend to have much higher incidences of smoking, alcohol use, less exercise and poor diet; yet, we are often silent about these. For people with HIV it is now the case that these things really do matter.

Share your comments and thoughts online at www.positivelife.org.au/talkabout or email editor@positivelife.org.au

References:

1. A van Sighem, L Gras, P Reiss, and others. Life Expectancy of Recently Diagnosed Asymptomatic HIV-infected Patients Approaches That of Uninfected Individuals. 17th Conference on Retroviruses & Opportunistic Infections (CROI 2010). San Francisco. February 16-19, 2010.
2. C Lewden and the Mortality Working Group of COHERE. Time with CD4 Cell Count above 500 cells/mm3 Allows HIV-infected Men, but Not Women, to Reach Similar Mortality Rates to Those of the General Population: A 7-year Analysis.

CROI online

To find out more about CROI or watch the online presentations, visit www.retroconference.org/2010 > Webcasts and Podcasts

You can play audio and slides or video and slides to listen to presentations. The best way to find topics of interest is to search the Session Title tab. Some sessions of interest include:

• Oral Abstracts: Advances in ART
• Oral Abstracts: Long-term Complications: Hearts and Bones
• Oral Abstracts: Neuropathogenesis: Clinical Correlates and Impact of ART
• Oral Abstracts: Treatment Outcomes in Women and Children
• Symposium: New Strategies for a Changing Epidemic
• Symposium: Pathogenesis and Clinical Management of Complications
• Symposium: The Future of HIV Therapeutic Research—The Treatment Agenda
• Themed Discussion: Got Milk? Vitamin D Deficiency Prevalence and Associations
• Themed Discussion: Progression of Atherosclerosis: Role of Inflammation and T Cell Activation
• Themed Discussion: Renal Disease: Mechanisms and Outcomes

Each of these sessions includes multiple presentations and you can skip to the ones that interest you.