We have been in a new era of HIV disease for at least 20 years. In the 1980s, HIV was a 1-3 year death sentence. In the 1990s, maybe 3-5 years for many, although some survived longterm. In the past 20 years, death from HIV-associated infections or malignancies became rare for those on treatment.
So, HIV people were now surviving for decades with the virus. With that, another aspect of HIV biology and damage emerged. HIV, even well-controlled (undetectable virus blood levels and good CD4 counts), was causing twice as many heart attacks and 3-4 times as many strokes as in the general population. So, if you live long enough with HIV, the reservoir virus appears to either directly or indirectly (? immune system inflammation, “bad” LDL cholesterol metabolic changes, or other, not yet understood disease mechanisms) cause damage to the coronary and cerebral arterial systems.
Of course, none of this sounds good, but it only happens because HIV people are living long enough for it to happen. It is just a way of aging peculiar to HIV patients. We all age one way or another and we all die. This is just an HIV-specific phenomenon.
What good can be made of this? After a long career spent on the worst things that can happen to people, I am devoted to the idea that every dark cloud has a silver lining. Then, what about this? Well, the problem exists whether or not we know about it. Being aware of it brings attention to it and to everything that makes it more likely, which is the beginning of possible solutions for minimizing it. So cardiovascular health is now your top priority. In this regard, I will recommended to all my HIV patients the following,
- LDL (bad) Cholesterol Control
- Low fat/carbohydrate diet (as close as possible to a Mediterranean diet)
- Statin drugs,
- Pitavistatin, pravastatin, or rosuvastatin with high LDL levels
- Pitavistatin with normal LDL levels; has been shown to reduce a number of HIV-associated cardiovascular damage diseases by about 35%*
- Blood Pressure Control
- Aerobic Exercise: A minimum of 4 ½ hours weekly (divided up however you wish, but with minimum 30 minute exercise intervals); check current government guidelines at cdc.gov.
- Ideal Body Weight: Basic Metabolic Index (BMI) = 25 (exception is those with extraordinary muscle mass such as bodybuilders and athletes)
- A rough rule-of-thumb is that you should (if you were “normal” weight your last year of high school) weigh about 10-15% less than you did your last year of high school, or when you stopped growing.
This is so especially for those who accumulate fat preferentially around their middle—high correlation with coronary (heart) artery disease and blockages.
- Routine Cardiac Screening (no symptoms) Testing
- Possible cardiac stress test and/or cardiac calcium scoring CT scan starting at 40 and every 5 years thereafter if no symptoms or other indications of heart disease; this is to be considered individually with a physician based on overall cardiac risk factors.
Note: Insurance may not cover this if there are no cardiac symptoms since this is not yet an established standard-of-care. But, whether medical insurers cover something or not has nothing to do with medical necessity.
- Colchicine (Lodoco): 5mg daily*
- This anti-inflammatory gout medication has been FDA-approved to prevent a number of cardiovascular events by 31% (even in HIV negative patients).
- It is not to be used concurrently with clarithromycin, ketoconazole, cyclosporine, or nanolazine.
- It is contraindicated with severe kidney and liver disease.
- Moderate (minimize) Alcohol
*NOTE: After reading this, if you wish to try these medications, contact our office. If you are already on a statin drug for cholesterol it will be held if you start pitavistatin. If that drug fails to control your cholesterol levels, your original statin med will be added back later.
These medications will be prescribed as soon as they are available.
You can check with your pharmacist and let us know when you can get them; we will then prescribe them.
Finally, some further perspective. Many heart attacks are sudden death events—no warning and unforgiving. 60-70% of sudden cardiac deaths are associated with coronary (cardiac) artery disease, and about 10% with coronary disease suffer sudden death. Further, though studies have not yet defined this, I am confident in the coming years we will find that the HIV population who have been well-controlled on and adherent to treatment, have had HIV for at least 10-20 years, and who are at least 50 year-old will disproportionately to the general population be experiencing cognitive decline (dementia). If the HIV arterial circulation is being damaged to the tune of 3-4X increased strokes (“macro” nervous system tissue damage), it stands to reason that neurons (nerve cells) are being picked off continuously (without symptoms). That is, brain damage is ongoing. The science suggests that and it will be proven, ultimately. But, now is the time to protect your brain at all costs, proactively. And this HIV cognitive decline would most likely emerge much earlier in life than the usual Alzheimer’s patient. You do not need to wait for guidelines to be formulated by medical or government agencies. They are often slow to move as they develop conclusive evidence. The current data are enough to conclude what I have described are life and quality-of-life critical issues. This has not been written to create hysteria or frighten you. It was done as a forward-thinking, expert piece in my patients’ best interests. Were I HIV positive I would want to know all of this and to be empowered to take action.
The heart/brain health protective measures I have listed above are inarguably beneficial to anyone. So, who should take the medications directed at the accelerated atherosclerotic arterial damage process associated with HIV? Certainly anyone with other risk factors for such disease,
- Family history of premature coronary artery disease/heart attacks: men under 50, pre-menopausal women
- Hyperlipidemia (elevated LDL cholesterol)
- Diabetes mellitus
When the HIV damage to blood vessels begins no one can say, but, until consensus is available on this, it would seem prudent to take coronary and cerebral artery protection meds from the outset of HIV infection, provided you have no specific contraindications to them and you are monitored with regular bloodwork for adverse effects. You can research the possible adverse effects on the internet. Whether to take them at this time is a personal decision after discussing risk/benefit with your physician. I would start the meds as soon as diagnosed with HIV were it me.
I have written this to alert my patients because the above areas of focus on your circulatory health are within your control. You have the information. Now, it’s time to make a choice and to take action.
Edward R. Rensimer, MD