By Barbara Jungwirth , Myles Helfand
A decade ago, the New York City Department of Health launched an HIV prevention campaign titled “It’s Never Just HIV.” In a series of television and subway ads, the campaign aimed to increase condom use by depicting, sometimes graphically, the complications that people living with HIV (PLWH) are particularly at risk of developing over time. The campaign was deeply controversial: many advocates saw it as fear-mongering and stigmatizing, while others saw it as honest and necessary amid the rising incidence of HIV within the city among men who have sex with men.
Regardless of how you feel about a fear-based approach to HIV education, the underlying reality behind the campaign remains true a decade later: people living with HIV are more likely than the general population to develop a range of comorbidities, and we are still striving to pinpoint exactly why this is so and how we can best intervene to improve the health of our patients and clients.
This week, we analyzed a handful of recently published journal manuscripts that explore different facets of this persistent problem:
Modern cases of Kaposi's sarcoma in people receiving antiretroviral therapy (ART) may be due to a new form of the herpes virus, researchers suggest.
Increased incidence of Kaposi sarcoma in PLWH patients treated with ART
Although not as prevalent as at the beginning of the epidemic, Kaposi sarcoma is making a comeback among PLWH on treatment, Canadian researchers noted in a viewpoint published in AIDS .
Since 2003, reports of Kaposi's sarcoma (KS) have emerged among men with low white blood cell counts (PLWH) on antiretroviral therapy (ART) with sustained undetectable viral loads and no history of prior opportunistic infections. The authors speculate that the resurgence of this cancer may be related to a low CD4/CD8 ratio resulting from persistent immune activation. They note that an ongoing prospective cohort study they are conducting in Montreal has found an association between a higher CD8 count (and a resulting lower CD4/CD8 ratio) and the likelihood of developing KS.
A lower CD4/CD8 ratio is also associated with age-related diseases, which have been observed in PLWH earlier than in the general population, the authors state. Therefore, KS may be a disease of old age that is now appearing earlier among PLWH as they age. Other factors that may also play a role include new genetic variants of HHV-8, the virus that causes Kaposi's sarcoma, long-term viral synergy between this herpes virus and HIV, or other factors.
With so many unknowns, the authors of the viewpoint called for large international cohorts of people living with HIV (PLHIV) with and without KS, as well as HIV-negative people living with KS. “We strongly suspect that KS in PLHIV treated with ART constitutes a novel form of the disease that is emerging and needs further investigation.”
Heat treatment can help women eliminate HPV
HPV, which can cause genital warts and dysplasia, and ultimately cervical cancer, could be eliminated through heat treatment, Chinese researchers reported in Clinical Infectious Diseases .
HPV and cervical cancer are more common among women living with HIV than among women in the general population. In Liaoning Province, China, where this study was conducted, the prevalence of HPV in the general population is 10%.
The study included 53 women who tested positive for HPV variants that carry a high risk of cervical cancer. They were randomly assigned 1:1 to receive either heat or a sham treatment. Both involved heat applied directly to the cervix via a vaginally inserted device for 30 minutes per day for three days, plus two additional sessions seven to 13 days later. In the treatment arm, heat was applied at 44 degrees Celsius, compared to 37 degrees Celsius in the control (sham) arm.
Three months later, the HPV variants of interest had cleared in 85% of the 27 women in the treatment arm compared to 50% of the 26 women in the control arm. No significant adverse events were reported.
Current recommendations call for a watchful waiting approach to HPV if there are no cytological abnormalities. However, many women prefer immediate treatment to avoid repeated follow-up appointments and for fear of transmitting the virus to their sexual partners. The new heat method could provide a safe and effective way to achieve this.
The authors of the study called for large-scale prospective studies to confirm the results of their proof-of-concept trial.
New proposed framework for diagnosing HAND (HIV-associated neurocognitive disorder)
Poor performance on cognitive tests does not always mean that a person living with HIV (PLWH) has an HIV-associated neurocognitive disorder, researchers argued in Clinical Infectious Diseases . Instead, they proposed a new assessment framework that incorporates a range of variables beyond cognitive tests.
The majority of the 20%–60% of people with low birth weight (PLWH) worldwide who meet current HAND criteria are diagnosed with asymptomatic neurocognitive impairment. While HAND is a real problem for PLWH, especially in areas without universal ART, cognitive abilities operate on a continuum and are influenced by a variety of factors beyond test performance, the authors noted.
The novel framework proposed by the authors incorporates HIV-related brain pathology, comorbidities, and lifestyle and socioeducational factors to explain the multifactorial nature of neurocognition. They called for combining a clinical history of cognitive symptoms and the trajectory of potential decline with performance on cognitive tests and brain pathology. Brain pathology should be defined separately from test performance, they urged, and poor performance on such tests should not be labeled cognitive impairment if symptoms are absent.
To overcome the limitations of relying on self-reported symptoms, the study authors recommended seeking observer accounts, but admitted that this may be difficult if PLWH do not disclose their condition to family and friends.
The authors also noted that in low-resource settings, neuroimaging for brain pathology may not be available, necessitating a possible/probable/definitive diagnostic hierarchy based on symptoms and the exclusion of other diseases.
"We hope that this framework will lead to the development of new consensus criteria for classifying cognitive impairment in [PLWH], appropriate for the modern era of effective and widespread ART," the study authors concluded.
Diabetes rate among PLWH in Texas higher than the national average
In Texas, one in six people with low birth weight (PLWH) has type 2 diabetes mellitus, according to cross-sectional data from the state's Medical Monitoring Project reported in AIDS Care .
Nine percent of the general U.S. population has diabetes, which is a risk factor for cardiovascular disease. Both diseases disproportionately affect the southern United States; so much so that the U.S. Centers for Disease Control and Prevention has dubbed a stretch of counties from Texas to Pennsylvania the "diabetes belt."
The current study analyzed data on 989 PLWH in Texas between 2015 and 2017. Seventy-two percent of the participants were male, 68% were ≥ 40 years old, 31% were overweight, and 28% were obese.
Age and body mass index significantly predicted the likelihood of type 2 diabetes. Duration since HIV diagnosis was also associated with diabetes, but other HIV-related factors were not. Diabetes was more common among participants with less than a secondary education (20% in that group had diabetes) than those with more than a high school education (14% in that group), and among those relying solely on public insurance compared to those with private insurance (20% and 12%, respectively).
The overall prevalence of diabetes of 15% in this study is higher than in national US cohorts, such as MACS and D:A:D, probably due to different demographic characteristics, the authors wrote.
The study authors called for longitudinal research on the long-term risk of diabetes and its impact on mortality among people living with HIV/AIDS (PLWH). They also recommended that HIV care providers screen their patients for factors that may predispose them to chronic diseases, such as diabetes, and that HIV clinics promote healthy lifestyles, including nutrition education and an emphasis on physical activity.