HIV update - 17th January 2018

High rate of respiratory problems in HIV-positive smokers

Chronic obstructive pulmonary disease (COPD) is a condition in which the lungs’ airways become inflamed and narrowed and the lungs’ air sacs become damaged. COPD includes both chronic bronchitis (inflammation of the airways) and emphysema (destruction of the air sacs).

Smoking cigarettes is the most common cause.

Damage to the lungs makes it harder to breathe. When the damage is severe, it may also become difficult to get enough oxygen into the blood and to get rid of excess carbon dioxide. Symptoms may include shortness of breath, coughing, spitting up phlegm, wheezing and tiredness. Unfortunately, the symptoms of COPD cannot be completely eliminated with treatment and the condition usually worsens over time.

A new study has looked at the respiratory health of smokers over the age of 40, comparing HIV-positive people and HIV-negative people. It found that those living with HIV were more likely to have airway obstruction, a sign of poor respiratory health. They may also be more likely to have COPD, although further tests would be needed for a diagnosis.

All participants were either current smokers or had quit in the previous three years. The researchers matched the HIV-positive and HIV-negative participants for age and gender. Those living with HIV had well-controlled HIV, but had all had a CD4 count below 350 at some time in the past.

Airway obstruction was assessed with a breathing test that measures how much air is going into the lungs and how rapidly air is inhaled and exhaled in the lungs. Airway obstruction was diagnosed in 19% of those with HIV, compared to 8% of those without HIV. Older people and heavier smokers were also more likely to have the problem.

People with HIV, especially those who’ve previously had low CD4 counts, are more likely to have a history of serious lung disease. This can make other respiratory problems more likely later on. But when the researchers excluded HIV-positive people who’d previously had tuberculosis or pneumocystis pneumonia (PCP) from their analysis, rates were still higher in those with HIV. This suggests that previous lung disease is not the only explanation for these high rates.

The study is another reminder of the damage smoking does to the health of people living with HIV. It seems to be even more harmful than for HIV-negative smokers.

For more information, read NAM’s factsheet ‘Smoking’.

Long-acting injectable ARVs

People who took injectable cabotegravir + rilpivirine every four or eight weeks as HIV treatment found it more convenient and discreet than daily pills, also feeling that it eliminated a “daily reminder of living with HIV”, according to a new study.

Researchers interviewed people who had taken part in an early clinical trial of the long-acting injectable antiretrovirals (ARVs) in the United States and Spain. Injections occurred every four or eight weeks, depending on which study arm a person was randomised to. This was the first HIV treatment the participants had taken and most had chosen to take part because they were interested in the idea of injections. So their responses won’t necessarily be representative of everyone living with HIV.

Most trial participants had had some side-effects from the injections, typically soreness and minor bruising at the injection site for a day or two. Nonetheless, most felt that the side-effects were “worth it” and could easily be managed with painkillers.

Many people found the injections more convenient, easier to adhere to and more private than daily pills. Other people would not inadvertently see their medication, making nights out and travel easier. However, a few participants did express concern about the number of clinic visits required – at least once a month for some people.

One man said the injections allowed him to carry on with his normal life:

Taking the pill everyday keeps HIV present… and the shot is just once a month… You remember it when you come in and the rest of the time you can basically forget it.”

One older man said that as he needed to take several other tablets for other health conditions, he was happy to stick with the pills.

While most participants said that they would recommend injectables to ‘anyone’ living with HIV, healthcare providers didn’t think that they would be right for everyone. Doctors also pointed out that the clinical management of long-acting injectables is more complex. You need to start with daily pills, then switch to injectables. After an injection, the drug stays in the body for several weeks or months, making it hard to stop the drug and get relief if there are side-effects. For similar reasons, there could be problems with drug resistance after stopping injectable treatment.

The healthcare providers also said that while people who find it hard to take a pill every day might theoretically be good candidates for injectables, people still need to show up for clinic appointments. So injectables won’t necessarily eliminate the problem of adherence.

A ‘mini-pillbox’ you swallow

Long-acting injectables aren’t the only alternatives to daily pills that are being investigated. Last week researchers announced that they were working on a device that is swallowed and can gradually deliver drugs over the course of a week.

Tests have been done on anti-HIV drugs – dolutegravir along with cabotegravir and rilpivirine (the two drugs included in the injections described above). The ‘mini-pillbox’ is at an earlier stage of research than injectables – the studies so far have been done with pigs. Human studies will follow.

The device is swallowed once a week as a capsule. Inside the stomach, the outer layer dissolves and the device inside opens up in the shape of a starfish. Over seven days, it releases daily doses of anti-HIV drugs before breaking up and passing through the digestive system.

The pilot study showed that concentrations of each drug remained high. However, some other anti-HIV drugs could not be delivered with this method as they are unstable in the presence of stomach acid. 

More bone loss in women than men

Bone mineral density (BMD) declines twice as quickly among HIV-positive women than HIV-positive men, according to a new study. Lower BMD in the spine and hip means that the bones have lost some of their strength and there is a greater risk of a broken bone following a fall.

The study is the largest ever analysis of long-term changes in BMD in people living with HIV. While bone problems are especially common for women who have gone through the menopause, the study found a faster decline in BMD for women, even after taking this into account.

Some risk factors for bone problems cannot be changed, like age and sex. But the study did identify some risk factors which people can do something about:

  • Low bone mineral density was more common in people who didn’t get any physical exercise. Walking, running, jumping, dancing, weightlifting and other weight-bearing exercises are beneficial for your bones.
  • Low BMD was more common in people with low levels of vitamin D. Key sources of vitamin D are summer sunshine, oily fish and vitamin supplements.
  • Low BMD was more common in people living with hepatitis C. Treating the infection is likely to be beneficial.
  • Low BMD was more common in people who had taken the anti-HIV drug tenofovir DF for longer. Switching to a different anti-HIV drug may result in improvements.

For more information, read NAM’s factsheets ‘Bone problems and HIV’ and ‘Menopause and HIV’.


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Community Consensus Statement on Access to HIV Treatment and its Use for Prevention

Together, we can make it happen

We can end HIV soon if people have equal access to HIV drugs as treatment and as PrEP, and have free choice over whether to take them.

Launched today, the Community Consensus Statement is a basic set of principles aimed at making sure that happens.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.