Lipodystrophy may be irreversible
Fat redistribution in people with HIV who once took some older anti-HIV medications persists. It is also associated with an increased risk of abnormal cholesterol and high blood pressure, even several years after stopping the treatment.
The drugs are zidovudine (AZT), stavudine (d4T) and didanosine (ddI) – medications from the nucleoside reverse transcriptase inhibitor (NRTI) family which are now rarely used.
The Danish study which came to these conclusions compared 451 people living with HIV who had taken AZT, d4T or ddI; 310 people with HIV who had never taken those drugs; and 2283 people in the general population.
The individuals who had taken AZT, d4T or ddI had done so for an average of six and a half years, but had stopped taking them an average of nine years ago.
The researchers measured participants’ visceral fat around the organs (the drugs are thought to cause an accumulation of this specific type of fat). They found more visceral fat accumulation in people who had taken these older medications (116 cm2) than in HIV-positive people who had not (89 cm2) or in HIV-negative people (106.5 cm2).
They found that each year of taking those specific anti-HIV drugs was associated with a 3.7 cm2 larger area of visceral fat. However, the length of time that had passed since people had stopped taking those drugs was not associated with having less visceral fat.
Also, in people living with HIV, more visceral fat was associated with a higher risk of high blood pressure, raised total cholesterol and lower HDL (‘good cholesterol’).
The researchers say that this harmful effect of the drugs appears to be irreversible in the time frame of their study (nine years, on average).
Atripla every other day
This wouldn’t work with most anti-HIV medications, but is a potential strategy with specific drugs which have a long half life (meaning that they remain in the body for longer than others). It appears to work for people who have already achieved an undetectable viral load with daily dosing of conventional HIV treatment. We don’t know if it would be safe for people starting HIV treatment for the first time.
The study was done with people taking Atripla, which is a tablet combining efavirenz, tenofovir disoproxil and emtricitabine. In the UK and other European countries, this is now becoming available as a generic medication. Nonetheless, HIV treatments that contain efavirenz are now out of favour in wealthy countries, due to concerns over psychological symptoms. Efavirenz and this specific combination are still frequently prescribed in developing countries.
A handful of previous studies trying alternative dosing regimens with efavirenz-based combinations have been tried successfully before, including a five-days-on and two-days-off strategy. In the new study, the approach tried was to take the medication every other day (in other words, every 48 hours).
Just under 200 people were randomly allocated to continue with daily dosing or to try alternate-day dosing. Self-reported adherence was better in the alternate-day group. While levels of efavirenz in blood were significantly lower in the alternate-day group, this did not affect viral suppression. After 48 weeks, 97% in the daily group and 94% in the alternate-day dosing group still had an undetectable viral load. This is a small difference that could be due to chance. The researchers’ conclusion was that both dosing schedules are equally effective.
Doctors and nurses should discuss U=U with all their HIV-positive patients
Healthcare providers should tell all patients with HIV they cannot transmit HIV to a sexual partner when their viral load is undetectable, argue the authors of a strongly worded comment article in The Lancet HIV. They say that despite overwhelming scientific data supporting the undetectable = untransmittable (U=U) message, significant numbers of clinicians do not educate their patients about U=U when telling them their viral load is undetectable. Doctors’ reasons include disbelief (not accepting that U=U), a perception that U=U would undermine personal responsibility and concerns about patients’ behaviour and understanding.
“Conveying benefits and risks surrounding any treatment is fundamental to patients’ decision making, and this HIV treatment benefit should be no exception,” they say.
One benefit of telling people with HIV is that it may encourage individuals to start and adhere to their treatment. There are additional benefits both for their own health and to the wider community’s health, by reducing onward HIV transmission. Telling people also has psychological and social benefits, enabling people to have reduced anxiety around transmission and better sexual relationships, and reducing HIV stigma, both in people with HIV and in the wider society.
Attitudes to diabetes lifestyle advice
London clinicians offered people with HIV who were at risk of developing diabetes six one-to-one sessions with individualised lifestyle advice on diet, exercise and losing weight. They then interviewed people who had taken part, chose not to, or dropped out early, on how they felt about the sessions.
They wanted to know, is this kind of lifestyle advice helpful?
Most people were happy with the sessions, particularly appreciating improved knowledge, the skills they learnt and the personalised goals.
Those who managed to make behaviour changes were often motivated by having a sense of control over preventing diabetes. They tended to have more social support than people who did not achieve goals. Those who didn’t sign up to the sessions said that attending once a month would be difficult.
Some HIV-specific barriers to behaviour change came up in the interviews. Firstly, body shape changes associated with lipodystrophy affected some participants’ body image and comfort with exercise. Others worried that weight loss might lead to disclosure of HIV status or be seen as being due to HIV‐related illness.
Some worried about how weight loss would be perceived in their community – some participants of African origin and some gay men who identified as ‘bears’ felt that being overweight was culturally desirable.
Some interviewees attributed their increased risk of diabetes to the side-effects of HIV medications they had taken in the past. They considered lifestyle advice futile, and either did not achieve the goals that were set or chose not to take part.
But for interviewees who achieved more goals, their motivation was often to avoid having another health condition on top of HIV, with more pills to take.
Comparing their results before and after the intervention, people who took part had statistically significant reductions in glucose, weight and other risk factors for developing diabetes.
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