Preventative health for PLHIV: some key issues - Sean Slavin

4. HIV viral load and CD4+cell count by year 1 Source: Australian HIV Observational Database 1 Dashed lines indicate the years of retrospective data collection.

5. Clinical Infectious Diseases 2008 47(4):542–553 Age distribution of HIV positive MSM in Australia Thanks John Murray – NCHECR / UNSW Estimated number of people living with HIV

6. Multiple co-morbidities: HIV versus controls Guaraldi G et al. CROI 2010. Abstract 727 Comorbidities analysed: hypertension, Type 2 Diabetes Mellitus, Cardiovascular disease and osteoporosis Guaraldi G, CROI 2010 Abstract727

10. CVD risks – what we can influence

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Notas del editor

For People with HIV, ‘preventative health’ has carried a number of meanings historically, with two above all: prevention of secondary HIV transmission and prevention of HIV disease that would lead to AIDS. The first meaning continues to be mainly addressed through community based education and health promotion aimed at both HIV negative and positive people; and, since the mid-1990s, the second aim has been met using anti-retroviral therapies and two clinical measures: HIV viral load and CD4 cell count. As a result of significant success in reducing the incidence of AIDS related diseases, the focus shifted through the late 1990’s to try and understand the various drugs that had joined the armamentarium, some of which had unforseen and serious side effects. Over a ten year period, various side effects have been well documented and improved treatment options have meant the disappearance of the most serious. Now, PLHIV live on in the company of both the virus and the medications, gaining an average life expectancy that approaches the general population. In this context we are starting to see a new spectrum of diseases, some of which appear much like age related morbidities. The meaning of prevention is now evolving to include cardio-vascular disease, diabetes, liver and kidney disease and cognitive impairment. Thus, lifestyle factors that were previously marginal to many PLHIV and their doctors while they focussed on drug adherence and viral control, are re-emerging as important considerations in preventing these new diseases. To give a sense of how significant this shift has been, in two recent large clinical trials, SMART and ESPRIT, the combined mortality from serious non-AIDS illness was 1.5 times more likely than AIDS. HIV medicine is now seeing an extraordinary reappraisal of the definitions of disease. The sorts of conditions that once characterised AIDS are rarely seen anymore and the use of AIDS as a diagnostic category is fading from use in developed countries. There is nonetheless persistent and, on some accounts, increasing morbidity among the PLHIV population. Cardio vascular disease for instance has traditionally been regarded as a non-AIDS condition, but an emerging consensus implicates the virus and some treatments in its development. Some researchers are saying that the fact of having HIV is a risk for heart disease at least equivalent to smoking. AIDS maybe a thing of the past, but HIV related morbidity is not.
The gap between the two lines represents the increasing population of PLHIV – around a thousand every year who are not dying of AIDS. Around 17,500 Australians currently living with HIV infection. 1000 new HIV infections annually, an increase of around 38% since 1999. Average age of diagnosis around 40 years Australian AIDS related deaths continue to decline from 149 in 2000 53 in 2007 24 in 2008.
This graph shows that if we look at two key indicators of health among PLHIV, controlled virus and healthy immune system, we are doing better each year. Approx 65 – 70% Australians with HIV taking treatment Australian HIV positive population is across a widening spectrum of age.
At the same time as the PLHIV population ages there are pressures associated with what has been described as rapid ageing. PLHIV are living longer with the virus than ever before, but the ageing process seems to be accelerated among PLHIV. We don’t fully understand the aetiology. So while this distribution continues to move to the right, i.e. the average age of the population is increasing, we could draw a similar curve approximating the distribution of age related disease. The green curve approximates the distribution of age related morbidity in the general population and the red curve approximates the distribution among PLHIV i.e. age related morbidity is occurring at younger ages among PLHIV. It’s not difficult to appreciate the seriousness of the situation once these two curves start to significantly overlap.
This is another way to picture the same phenomenon. This slide was presented at the Retrovirus Conference in San Franscisco this year by Guaraldi and colleagues. It shows the high rate of co-morbidities of HIV-positive people compared with HIV-negative controls– at all ages. The most significant rate was amongst the over 60s where the rate of HIV-positive people with more than 2 co-morbidities as well as their HIV was 63% compared with 12% for the negative controls. If we are to understand some of the more subtle aspects of premature ageing, such comparisons between positive and negative cohorts are essential. In Australia, AHOD is starting to explore such comparisons.
We need to think about a range of possible health complications for PLHIV where the cause is unclear. HIV or ART continue to lead to some co-morbidities but the precise relationships /mechanisms are currently debated e.g. inflammation. We need further research on this as well as a focus on lifestyle risks.
The degree to which HIV, treatments or conventional risk factors play roles in triggering particular co-morbidities is unclear. Taking a particular view, however, has political consequences: for PLHIV and for the HIV sector. It is tempting to emphasise the lifestyle risks, because there is a building national agenda and indeed there may be opportunities associated with linking to mainstream health promotion efforts. However, there is also a threat that the very significant issues still associated with HIV and its treatment will be diminished. This same problem arises when thinking about ageing, which is an issue that NAPWA has decided to address in its work this year. On the one hand we can think of ageing as the umbrella term for a variety of specific co-morbidities that need to be studied and treated, or, as I’ve heard it said we could think about ageing as an inevitable fact of life coming to us all. The problem I have with the latter view is that it implies a level of passivity in relation to a set of issues that PLHIV face that require more urgent and concentrated attention.
Prevention and the role of treatments in the HIV field is further complicated when we think of the international debate that is now occurring about the use of ART among PLHIV with the aim of preventing secondary transmission rather than ensuring the best outcomes for the patient. An acknowledgement of the important role that HIV+ people play as equal partners in HIV prevention efforts has been hard won. Treatment as prevention risks being a backward step, if we aren’t vigilant. This issue highlights two public health tendencies that we ought to remain cautious of. First the tendency to prioritise the health of populations over the human rights of individuals and second, the very contemporary tendency to devolve responsibility for community health onto individuals. In order to critique the first tendency, for PLHIV we need to insist on the primacy of individual health and human rights, while seeing any population benefits from treatments as a secondary, albeit welcome effect. The second tendency is more pernicious, because it is emblematic of broader social tendencies that have been labelled by sociologists as “individualisation”. In HIV we have always been very cautious about making positive people unfairly responsible for HIV prevention, yet this is one of the possible implications of treatment as prevention. Thinking more broadly about the national preventative health agenda, notwithstanding the good intentions of the task-force in relation to addressing the social determinants of disease, the context of contemporary society means that the responsibility for prevention will tend to weigh more heavily on individuals and governments see this as an opportunity for cost saving. This is a political question that needs to be answered through a serious critique of social context including “old fashioned” notions like class, race and social power.
To give you an example of what I mean with regard to individualisation and responsibility, I recently gave a presentation to NAPWA members that looked at the evidence around HIV and cardio-vascular health. Among PLHIV rates of CVD are between 1.5 to 2 times greater than general pop. HIV and treatments are implicated in the elevated risk to some degree, but I was also trying to tell a good news story by emphasising that many of the risk factors were modifiable by pursuing the sorts of simple goals we understand well like exercise, smoking cessation and diet. Many in the audience were sceptical. Some people said things like: “I’ve managed to survive the virus for 20 years, treatment toxicities, depression, drug addiction and now you want me to get fit? Give me a break.” I think there are versions of this kind of argument circulating in the broader community in relation to the alcohol and smoking targets in the national framework and begs a question about how we promote lifestyle changes. Many people hear these messages as an individual impost or just dull. It seems no matter how much we talk about the social determinants of disease, changing unhealthy behaviours can end up feeling like a bridge too far for many individuals who hear the message as a comment on personal deficiency and the never ending demand for self improvement is overwhelming. As a result the whole message is discounted.
Health reform is moving fast – increasing role for primary health care to reduce reliance on hospitals. For politicians and bureaucrats this is what prevention boils down to – keeping people out of hospitals. We need to maintain a place for community based health promotion. Even good GPs are time poor as more is demanded of the 15min consultation. Many doctors prefer drug interventions when health promotion can be more time consuming and the outcomes unclear. We can work with GPs as we have in the past but the forces of medicalisation are strong.
Lifestyle is but one factor affecting non-AIDS morbidities. It’s becoming increasingly clear that HIV still plays a pivotal role. And we are still learning about the impact of using treatments over decades. The social context of health means that behaviours like smoking or alcohol consumption can have complex relationships with people’s social identities. Health is not a universally agreed good – for many people social identity is more important, even if it involves unhealthy behaviours. Prevention health missionaries armed with smoking cessation and exercise programs risk being greeted with cynicism by PLHIV unless we think carefully about what the useful messages are for a diverse population that is accustomed to subtle thinking about risks and benefits. The notion of “Quality of Life” is currently underutilised in health promotion and may be more useful than either “health” or prevention as hooks on which to hang activities, particularly for those already living with chronic illness.

Preventative health for PLHIV: some key issues - Sean Slavin

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Preventative health for PLHIV: some key issues - Sean Slavin

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