PALS
from the latest PALS newsletter (spring 2008)
(1)To
test or not to test - HIV screening explained
(2)HIV, HAART and Diabetes
For further information
about the issues covered in either of
these articles, or to discuss the implications for yourself as a
client, carer or health worker, please contact PALS by e-mail
or phone 0845 223 5209
To test
or not to test - HIV screening explained
by
Gill Bradbury, PALS Development Worker
Whilst this
is a personal decision, which requires individual consideration,
a proactive approach to testing, both personally and professionally clearly
has benefits - If diagnosed HIV positive, treatment can be started earlier
and there is less of a risk of infecting others.
Doctors are being reminded of appropriate indications for HIV screening
and the CMO recommends that it should be more frequently undertaken
than current statistics suggest it is. Genito-Urinary Medicine - physicians
must offer an HIV test to all patients on their first presentation for screening.
Last year BHIVA reported that a 1/3 of all deaths in people with HIV were
due to late diagnosis. This is quite shocking!
Understanding the test
In considering testing a person should know that it is a HIV (antibody - ELISA
or EIA) Test that they are having and not an AIDS Test - for which, there is
no such thing! The screening procedure - (including how & when results will
be given) should be fully explained. There should be a confidential
opportunity to gain a better understanding of the facts, and to discuss any
anxieties or issues, so as an informed decision & consent can be given.
HIV risk factors and approximate date of potential exposure will need to be
known. Most people develop HIV antibodies - (i.e. seroconvert) within a
couple of months. A recent - (post risk) flu-like illness and certain symptoms
can indicate (new) HIV infection and you should be aware of whether you
have experienced this type of illness or, any other symptoms.
To tell or not to tell?
Whilst it is important to gain support, it is necessary to carefully consider
who you might tell about going for a test and the subsequent result. The
reactions of friends & family are not always what might be expected…
and much ignorance & stigma still prevails around HIV. It is worth trying to
imagine how you might feel if you have an HIV positive - (or, a HIV negative
result) and on receiving the result, what would be your immediate concerns,
what you might need to do - if there are any `behaviour' changes that you
need to make, who to disclose to, etc.
False positives
A `false positive' can occur from antibody testing and any positive result
is always confirmed by a second, different type of test. If you are given an
HIV positive result, you would be offered counselling with the opportunity to
further discuss these issues and the next steps.
The next step
Referral would be made to
a Specialist HIV - (GUM) Clinic, where further blood testing would be
undertaken to identify your CD4 T-cell (blood) count and viral load.
Follow up and treatment - (HAART) would be initiated as appropriate and
according to blood results.
HIV,
HAART, Diabetes and Heart Disease
The prevalence of metabolic disorders such as: high triglycerides and
cholesterol, elevated ALT -(liver enzymes), hyperglycaemia, insulin
resistance, glucose intolerance and the development of Type II Diabetes,
has long been associated with the taking of HAART - (highly active
antiretroviral therapy) and these conditions have increased dramatically
following its widespread use. According to the MACS - (Multicenter AIDS
Cohort Study, US), HIV positive men who are on this medication are
(more than) four times more likely to develop diabetes than HIV negative
men. Equally, development of Type II Diabetes - (otherwise known as
Diabetes Mellitus) has been reported in 2 - 10% of people taking anti-HIV
treatment, with prevalence growing as duration on therapy increases.
J. Koeppe et al - (2006) state that this disease could be linked to HIV itself.
Diabetes
Within the general population, diabetes is a common disorder affecting
individuals of all ages with obesity (and lack of exercise) being major risk
factors. High levels of glucose and certain types of cholesterol also increase
the risk of cardiovascular problems and heart disease. Abnormalities in fat
and sugar (blood) levels and in the processing of fats and sugars may
indicate a metabolic disorder. Metabolism describes the breakdown of food
and production of energy within the body, of which sugar - (glucose) and fats
-
(lipids: cholesterol and triglycerides) are sources of energy.
Diabetes is a metabolic disorder, of which there are two types: Type I - (where
the body does not produce enough insulin; this type is usually diagnosed in
childhood or adolescence) and Type II. Type II Diabetes is caused by a reduction
in the body's ability to control blood sugar levels. It develops in adults due
to a
gradual decline in insulin sensitivity and a reduction of insulin production.
The pancreas generates and secretes insulin, which is a hormone that enables
the uptake and storage of nutrients - (glucose, proteins and fat) - within the
tissues of the body and which, regulates glucose levels in the blood. Glucose
is needed to produce energy - (to fuel the activity of the calls). When insulin
is
absent or ineffective, the cells receive inadequate amounts of glucose and the
body compensates by releasing more glucose. The excess glucose can't be
absorbed and the glucose levels in the blood & urine rise, leading to hyper-
glycaemia (high blood sugar) and possible physical symptoms: fatigue,
frequent urination and consequent thirst, weight loss, dizziness - (due to high
BP),
loss of concentration and blurred vision. More serious problems can occur in
cases of severe Type II Diabetes such as: Lesions in the retina of the eye;
kidney
disorders - (diabetic nephropathy); nerve damage, particularly in the legs -
(diabetic neuropathy); impotence; bacterial or fungal skin infections and
cardiovascular disease - (angina, atherosclerosis, stroke, heart disease, etc).
HIV, HAART and Diabetes
In addition to the use of antiretroviral therapy, HIV disease severity and CD4
count
may also increase the risk of hyperglycaemia and its associated problems
- (Brown, 2004). Co-infection with HCV - (Hepatitis C - Butt, 2003 & Mehta,
2003)
also appears to increase the risk of diabetes and hyperglycaemia; this may be
of particular importance in people aged over 40, as may a history of acute
pancreatitis - (Crane, 2004). Whilst metabolic changes, sugar and fat level
abnormalities often produce physical symptoms, many people are unaware of
these or, the raised blood levels that put them at risk of diabetes and/or heart
disease - diabetes itself significantly increases the risk of heart disease.
Regular testing
Good Primary & Specialist Care for HIV-infected individuals - (with diabetic,
lipid and liver reference, monitoring and follow up for related side effects
or
complications) is therefore very important. Regular glucose level monitoring
in
people receiving HAART should be undertaken so as steps can be taken to
reduce rising levels before diabetes develops. However, Type II Diabetes
may be acquired soon after beginning a new drug combination; in some cases,
within a matter of weeks. Lipid levels - (Cholesterol & Triglycerides) should
be tested prior to starting antiretroviral treatment, then regularly once treatment
has begun. They should be tested first thing in the morning - (on an empty
stomach) to get the most accurate measure: this will show the absolute
minimum (fasting) level. Triglyceride levels also need to be tested after a
meal,
because they rise very high within an hour or so of eating. Triglycerides are
fatty acids - derived from fats, carbohydrates and excess alcohol and which
are stored in fat tissue and the liver.
Cholesterol
Cholesterol is another type of lipid whose physiological purpose includes
hormone production and cell formation. It's not soluble and binds to proteins
in the bloodstream, producing `lipoprotein complexes'. There are 2 types of
cholesterol - `good' and `bad'. The good cholesterol - (called HDL - high
density lipoprotein) offers a measure of protection against heart disease but
is often reduced in people living with HIV or other chronic illnesses. The bad
one, known as LDL - (low density lipoprotein) increases the risk of heart
disease if levels are high and if HDL is correspondingly low. HAART and
lipodystrophy have been associated with high LDL and high total cholesterol
levels.
Lipodystrophy
Lipodystrophy is a condition of abnormal fat redistribution - changes in the
amount and location of body fat. This can lead to, either: lipohypertrophy (fat
accumulation in specific areas - neck / shoulder blades, central abdominal fat
- belly, upper torso and breasts) or lipoatrophy (fat loss / wasting in the
face,
buttocks, arms and legs). Central obesity is known to predispose people to
Type II Diabetes because fat around the organs is highly insulin resistant.
LDL rises may occur after starting treatment, particularly with combinations
including most of the PIs - (Protease Inhibitors). It is thus very important
to
monitor levels of LDL as well. There are other risk factors which, if combined
with high LDL (and total) cholesterol levels and / or, low HDL levels, increase
the chance of heart disease further. These include: smoking, high BP
(above 140/90), familial history of heart disease, physical inactivity and lack
of regular exercise, obesity - (particularly central fat accumulation), male
over
45 years / female over 55 years, stimulant use - (cocaine & amphetamines),
excess alcohol use, diagnosis of diabetes or insulin resistance and high
triglyceride levels. HIV itself causes high triglycerides in advanced disease
and very high levels of triglycerides may also cause (acute necrotising)
pancreatitis - a life-threatening illness. If you have two or more risk factors,
the target level for LDL cholesterol is less than 3.4mmols/litre. The target
total
cholesterol level is 5.2mmols/litre or below. The average cholesterol level
in
the UK is higher than this (around 5.6), and a level of 5.9 or above is high.
The triglycerides target level is 2.3mmols/litre or less, and a level above
4.5mm
is considered high.
HIV medications
The British HIV Association - (BHIVA) Guidelines recommends that people
with a fasting level of above 8mmols/litre and a total cholesterol level above
6.5mmols/litre (or, an LDL to HDL cholesterol ratio of greater than 4) should
: switch to a PI-sparing regimen - (if taking first regimen), stop smoking,
increase exercise levels, adjust diet and undergo drug therapy - Fenofibrate
or, Gemfibrozil and Pravastatin or, Atorvastatin, respectively. It is known
that:
Indinavir - (Crixivan) can cause insulin resistance and switching therapies
may
reduce glucose levels. Various (oral) drugs are available for controlling
hyperglycaemia and diabetes although some of them - (the Sulphonylureas)
may cause weight gain of up to 5kg - (which may or may not be desirable)
and Glyburide is contraindicated in people with renal insufficiency.
An alternative first line treatment is Metformin - (Glucophage) which may also
be effective in reducing abdominal fat deposits and encouraging weight loss.
It is also known to reduce triglyceride levels and improve glucose metabolism.
However, it can also cause lactic acidosis in people taking 'Nucleoside Analogue
Reverse Transcriptase Inhibitors' - (NRTIs) and gastro-intestinal side effects
-
(abdominal pain, nausea & diarrhoea) in the first few weeks of treatment.
A third class of drugs are the Thiazolidinediones - (often referred to as Glitazones)
and which have also been shown to improve HDL Cholesterol, reduce triglyceride
levels, lower BP and reduce clotting, although their impact on the risk of
cardiovascular disease per se, has yet to be established. Of this class of drugs,
there are some concerns about the use of Rosiglitazone in HIV patients as it
appears to elevate lipid levels. Finally, a combination of oral medication may
be
used and insulin therapy is available for the more severe cases of Type II Diabetes
- (some experts believe that earlier use of insulin may result in more frequent
remission of Type II). As suggested, lipid levels can be improved by switching
from a PI - (Protease Inhibitor to an NRTI - (Nucleoside analogue Reverse
Transcriptase Inhibitor) or Abacavir-containing regimen. Equally, fat loss from
the arms, legs and face may be improved somewhat by switching from d4T -
(which also causes rises in lipid levels) to Abacavir or Tenofovir.
Statins
Statins are lipid lowering drugs which have been used successfully to lower
lipid levels in people on HIV therapy. Pravastatin is most often used. Clearly,
initiating any treatment combinations or changes and other medication to
counter side-effects is a complex issue, requiring specialist advice and
interventions. Both central fat deposits and lipid levels have been improved
by a combined programme of resistance exercise and aerobic exercise.
Resistance exercise builds muscles which burn triglycerides, and aerobic
exercise - (brisk walking, jogging, cycling, swimming, etc) - where the heart
rate rises above its normal rate for at least 20-30 minutes each day, reduces
the risk of heart disease (by 1/3), as well as diabetes through increasing levels
of good cholesterol and normalising blood glucose levels.
A healthy diet
A healthy diet also plays a part in this and changes recommended for people
with diabetes - (or those who are overweight) include: " Increasing fibre
by eating more whole grains, pulses, beans, fresh fruit & vegetables. "
Increasing consumption of polyunsaturated fats - (sunflower, safflower,
soybean & corn oils). " Reducing consumption of saturated (animal) fats
such as lard, butter & cream. " Reducing consumption of trans-fatty acids
- (eg. margarine & products containing it) and hydrogenated fats found in
prepared foods and some ready meals - (eg. cakes, biscuits, pizza, etc).
Diet - a warning note
For PLWHA, consultation with a Specialist HIV Dietician is
recommended before commencing a diet for diabetes. It must be ensured
that such a diet will not interfere with the absorption of anti HIV drugs,
adversely affect levels of blood fats or worsen wasting.
For
further information about the issues covered in either of
these articles, or to discuss the implications for yourself as a
client, carer or health worker, please contact PALS by e-mail
or phone 0845 223 5209