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Last call: HIV patients endangered by smoking, drinking alcohol
HIV + age + risk behaviors = heart, lung disease
To quote the late great Mickey Mantle, "If I knew I was going to live this long, I'd have taken better care of myself." Those with HIV find themselves in a similar situation, as a once fatal disease extends to a chronic condition imperiled by two classic bad habits: drinking and smoking.
Mounting evidence suggests that HIV-infected patients have an increased risk of cardiovascular, liver, and pulmonary diseases, and that the risk increases with behaviors that are common with this population. Researchers and other experts say these studies highlight the need for clinicians to focus on educating patients about quitting smoking and alcohol use.
"Smoking is a leading cause of mortality worldwide, and it is one of the major risk factors for many comorbidities, particularly pulmonary diseases. There's potential for an enhanced risk for harm associated with smoking among HIV-infected persons," says Kristina Crothers, MD, an assistant professor at the University of Washington School of Medicine and Harborview Medical Center in Seattle, WA.
Emerging research shows that HIV patients have an increased risk for chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary fibrosis, and pulmonary arterial hypertension, in addition to pulmonary infections like bacterial pneumonia and opportunistic lung infections.
"And smoking is an additional risk factor for a lot of these diseases," she adds. "We published a paper several years ago, demonstrating an increased risk of mortality among HIV-infected current smokers in the antiretroviral era."
Before the combination antiretroviral therapy (ART) there was conflicting evidence about whether smoking was associated with increased mortality among HIV-infected populations.
Now, however, there's a shift among the HIV/AIDS research and within the public health community in the perception of smoking as a risk factor for comorbidities and mortality, Crothers says.
"Other studies also have been published showing similar findings, and there is increased emphasis in the literature on smoking and smoking cessation in HIV-infected populations," she adds.
A direct link between alcohol and death
In the Veterans Aging Cohort Study (VACS) involving thousands of HIV-positive veterans, investigators discovered a linear relationship between drinking and mortality, says Kendall J. Bryant, PhD, director of alcohol and HIV/AIDS research in the Office of the Director, National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the National Institutes of Health (NIH) in Rockville, MD.
"Maybe this relationship involved biological issues and organ involvement, but it showed no benefit to drinking whatsoever at any level," Bryant says. "There used to be the idea that if you drank a little it was sort of good for you, but we found a straight line between the number of years of life lost from potentially living with HIV and the amount you drank even at very low levels."
In addition, a study presented recently at the recent 18th Conference on Retroviruses and Opportunistic Infections (CROI) concluded that HIV infection is associated with an increased risk of myocardial infarction (MI) events after adjusting for smoking and other risk factors.1
This research builds on a growing body of evidence that suggests HIV is an independent risk factor for cardiovascular disease, says lead researcher Matthew Freiberg, MD, MSc, an assistant professor of medicine and epidemiology at the University of Pittsburgh (PA).
Investigators looked at an HIV-infected cohort and compared them to an uninfected cohort in VACS. Both cohorts were similar in demographics and behavior, including smoking, alcohol use, and cocaine use.
MI risk factors included age, smoking, and renal disease, Freiberg notes.
"When we looked at the risk factors of the 82,000 people in this population, HIV had a two-fold risk," he adds.
"The next obvious question is 'How much of it is the virus, and how much of it is the treatment?'" he says. "And that's impossible to know because you can't randomize people to HIV infection."
However, Freiberg and co-investigators compared HIV patients with suppressed viral load on continuous antiretroviral treatment (ART) with those who were on intermittent ART, and they found the group on intermittent ART had worse cardiovascular outcomes.
"That suggests the virus is playing some role here," Freiberg says.
It's difficult to separate the impact of HIV infection from the impact of antiretroviral drugs and various environmental and demographic factors involved in cardiovascular and lung diseases, researchers say.
"Evidence strongly suggests that HIV is an independent risk factor for cardiovascular disease, so the other risk factors need to be managed as best as possible," says Cheryl L. McDonald, MD, medical officer and program director at the National Heart Lung and Blood Institute (NHLBI) of NIH in Bethesda, MD.
"Studies are still going on, but evidence strongly suggests it's a strong risk factor for premature and accelerated cardiovascular disease," McDonald says.
This suggests that HIV clinicians should stay attune to patients' symptoms of cardiovascular disease and assess their other risk factors, including lifestyle issues like smoking, drinking, and exercise, she adds.
"This is just further evidence that it's imperative that doctors stress risk factor reduction and use this information to encourage patients to minimize their risks, McDonald says.
Smoking may tend to be toward the bottom of the list of HIV clinic visit priorities because it can be so difficult and time-consuming to change, Crothers says.
"It needs to be a cultural change for patients, and providers need to look at it as something on par with other risk behaviors in terms of mortality and impact on overall health and quality of life," she explains.
HIV clinicians might also overlook smoking behaviors because unlike alcohol and illicit substance use, cigarette smoking is not clearly associated with increased risk of HIV transmission, Crothers adds.
"That may impact prioritization, as well," she says.
Surprise: Weight gain and HIV
Weight gain is another risk factor, says Amy Justice, MD, PhD, section chief of general medicine at West Haven Veterans Affairs Healthcare System and professor of medicine at Yale University School of Medicine, both in New Haven, CT.
"One thing that's different about folks with HIV is they tend not to be overweight when they start antiretroviral therapy (ART), but then they begin to put on weight with ART," she adds. "So I try to get colleagues to say to their patients, 'Don't let yourself get heavy – it's a lot easier to keep the weight off than to take it off once you put it on, especially in middle age.'"
HIV patients who have liver disease and hepatitis C can improve their health and liver function by losing weight and abstaining from alcohol, she says.
"Obesity contributes to fatty liver and liver inflammation," Justice says. "We have to think about substance use in HIV patients in middle age, weight control, managing severe mental illness – all challenges the general pediatric community hasn't taken on because this is a special population."
It makes no sense for HIV clinicians and researchers to focus on just one condition that might cause heart disease and other problems in HIV-infected patients when most people with HIV tend to have several problems that contribute to a cumulative injury, she notes.
"Together these can have a cumulative effect that may be more devastating than any one of those conditions would be," Justice says.
The key might be to target the risk behaviors that can be controlled, even if these involve comprehensive behavioral strategies, the experts say.
"We're already controlling diabetes and blood pressure, but with the prevalence of risk factors, do we need a chronic care model for risk factor reduction?" Freiberg says.
For example, an HIV patient who has a heart attack will have several specialists overseeing his or her care, including an infectious diseases physician, an internal medicine physician, and a cardiologist, he says.
"Why not have coordinated care between the three doctors focused on the goal of tobacco cessation?" he says. "Physicians want to help, but it's sometimes not clear what the right strategy or intervention is, and there are a lot of different ways to approach it."
The HIV medical community needs to put these latest findings regarding HIV and cardiovascular disease into perspective, McDonald suggests.
"Twenty-five years ago, you didn't worry about their hearts," she says.
"Now there are HIV doctors, infectious disease doctors and family doctors coming out of training who never saw their HIV-infected patients dropping dead, and that's just amazing to me," McDonald adds. "With what other infectious disease have we had that much progress so quickly?"