What did we miss while treating HIV?

Dr BB Rewari, NACO
Bobby Ramakant - CNS
Expanding access to antiretroviral therapy (ART) and HIV care services have helped people living with HIV (PLHIV) to survive and lead a better quality of life, but closing our eyes to other non-HIV healthcare needs can also reverse health benefits. “PLHIV on ART are at an elevated risk of cardiovascular diseases [CVDs],” said Nazisa Hejazi, from the University of Kebangsaan, Malaysia. “PLHIVs often have traditional NCD risk factors such as taking high fat intake, smoking, physical inactivity among others. We also know that ART medications affect the liver, potentially leading to metabolic disorders”

Non-communicable diseases [NCDs] such as CVDs, particularly coronary heart disease and type-2 diabetes, were stressed as emerging health issues in HIV by UNAIDS earlier this year, and may be associated with the initiation or ARTs. Since 1998, data have highlighted CVDs as one of the serious causes of death among PLHIV. One study data from 33 countries (including Thailand) showed that CVD rates among PLHIV were as high as 1-in-10. Other clinical manifestations of metabolic abnormalities as a result of ART include: dyslipidemia, insulin resistance, and lipodystrophy (peripheral fat loss, visceral obesity).

Levels of ‘bad cholesterol’ (or LDL) are higher in people taking ART, potentially increasing their risk of high blood pressure and CVDs. Some studies show there is at least 20% more CVD risk for PLHIV as a result. Hejazi said that it is very important for PLHIV to keep their viral load low as it results in less inflammation. Hejazi cautioned that preventing NCDs is more important among PLHIVs because adding to ‘pill burden’ is not going to help in adhering to life-long regimens of ART.

Dr BB Rewari from the India National AIDS Control Organization (NACO) added: “Cardiac abnormalities are directly responsible for deaths in 11% of children living with HIV.” In a study of 100 children (i.e. below the age of 18 years) living with HIV (but with no pre-existing congenital or acquired heart disease) ECG and other CVD-related indicators were monitored. 4% were found to have palpitations, one patient had a breathing difficulty, 2% had grade-II systolic murmur, 1% had muffled heart sounds and 3% had cardiomegaly.

“Echocardiographic abnormalities were found in 50% children living with HIV and 37% had left-ventricular dysfunction,” said Dr Rewari. “There is increasing incidence of cardiac involvement in children after initiating ART, but it is less documented.”

Dr Hongjie Liu shared data from China highlighting that the proportion of PLHIV aged 50 years or older has risen dramatically, from 2% in 2000 to 21% in 2011. Whether AIDS programmes are attending to age-related issues is not clear. In Nanning, capital city of Guangxi province, a cross-sectional study showed significant increases in mental health issues among older PLHIV. “Intervention programming that focusses on improving mental health and quality of life is greatly needed for older PLHIV in China,” said Dr Liu.

“In our experience, adherence was a major challenge among older PLHIV in Myanmar. Mental health issues and alcoholism can adversely impact PLHIV,” said Khine Mar Aung, Programme Support Officer of the International HIV/AIDS Alliance in Myanmar. “We also need to strengthen health systems. Long waiting times, non-privacy or small waiting areas in hospitals make PLHIV uncomfortable and compromise confidentiality.”

Dr Taweewat Supindham from the Research Institute for Health Sciences in Chiang Mai University in Thailand, said: “Although human papilloma virus (HPV) rates in Thai women were 8.7%, among MSM and transgender people in northern Thailand anal HPV rates shot up to 80%. There are more than 40 types of ano-genital HPV.” HPV infection is associated with cervical cancer and anal cancer. Recently HPV vaccination has been implemented for young women in Thailand but is not available for MSM or transgender people.

Bobby Ramakant, Citizen News Service – CNS
November 2013 

Note: This article was first published in 11th ICAAP INSIGHT, the official daily conference newspaper of 11th International Congress on AIDS in Asia and the Pacific (11th ICAAP) in Bangkok, Thailand. This newspaper was managed by Inis Communication and CNS.