Time To Stop Smoking: New Study Shows Deadly Effect of Smoking on People with HIV

Here is a study by Helleberg and colleagues looking at smoking-related mortality in HIV patients in Denmark. For people with HIV (in a country where HIV care is organized and antiretroviral therapy is free), smoking was associated with more years of life lost than HIV itself.

These authors looked at 2,921 people with HIV followed in the Danish HIV Cohort Study (from 1995-2010) with 10,642 controls taken from another large population-based cohort.

HIV positive smokers were 5.3 times more likely to die from a non-AIDS related death (cardiovascular disease, cancer, et cetera) than HIV positive non-smokers. AIDS related mortality was higher in HIV positive smokers, as well; they were 4 times more likely to die from an AIDS-related death than HIV positive non-smokers.

The authors estimate that a 35 year old HIV positive smoker has a life expectancy of approximately 63 years; an HIV positive non-smoker has a life expectancy of 78 years. In terms of years of life lost, smoking was associated with 12.3 years of life lost (versus only 5.1 years lost associated with HIV).

Although one could argue that these findings may be difficult to extrapolate to settings outside Denmark (where, again, HIV care is well organized and antiretrovirals are free), these findings are compelling and have implications for managing HIV positive patients worldwide. Although healthcare providers are well aware that smoking causes all sorts of health problems and is associated with increased mortality, this study quantifies the deadly effect of smoking on people living with HIV.

In an era where antiretrovirals have transformed HIV into a chronic illness, we need to re-double our efforts in counseling/ supporting HIV positive patients to stop smoking.

Alabama: Ending Segregation of Inmates with HIV

wikipedia.org

Here is a nice New York Times article about the recent Alabama court ruling against the state's policy of segregating inmates with HIV from other inmates. This practice is associated with social isolation, stigmatization, lack of access to certain educational programs and an inability to transfer to prisons closer to families. Inmates are forced to wear arm bands identifying them as being HIV positive, eat alone and are not allowed to work around food; another nice New York Times article about this can be found here.

My friend and colleague Dr. Gonzalo Bearman wrote a very nice blog piece about segregating inmates with HIV back in November that is also worth taking a look at.

wikipedia.org

The New York Times article notes that Alabama inmates are not isolated based on having the hepatitis B or C viruses, both of which are more infectious than HIV. All three viruses are transmitted through blood and body fluids. Activities such as having unprotected sex and tattooing (if needles or ink are reused) can lead to acquisition of any of these viruses.

Per the CDC, people who are incarcerated are at increased risk for both acquiring and transmitting HIV. The CDC does not recommend isolating inmates with HIV, however. Rather, the CDC recommends testing inmates for HIV at the time of facility entry and exit, providing educational and treatment programs to inmates who test positive and linking inmates with HIV to care when they are released.

The Alabama court ruling is a definite victory for inmates living with HIV in Alabama. More work needs to be done, however, as this practice of segregation is still in place in South Carolina. Beyond this, prisons and jails should consider adopting practices that will limit infectious disease spread across the board, such as making condoms available.

The Dangers of Recreational HIV Drug Use: "Whoonga"

Here is an interesting NPR story of HIV drugs being used as recreational street drugs. Apparently this is a real problem in South Africa, although the issue has not generated a lot of press to date.

People crush anti-HIV drugs such as efavirenz and or ritonavir and mix these together with illicit substances (such as methamphetamine, opiates or marijuana) and smoke the concoction. In South Africa one such mixture is dubbed "whoonga").

Efavirenz can cause neuropsychiatric side effects (things such as vivid dreams). Ritonavir may boost the effect of other illicit substances.

A 2011 article on whoonga use from the BBC provides a nice overview of this problem in South Africa. A nice commentary piece published in the The Lancet Infectious Diseases on the recreational use of HIV drugs by Grelotti and colleagues (and on which the above NPR story was based) can be found here.

A major problem related to recreational HIV drug use is the emergence of anti-HIV drug resistance. HIV is a viral illness that requires multiple different anti-viral medications used in concert to treat effectively. When the virus is exposed to these drugs intermittently or not in combination drug resistance can emerge rapidly. Smoking "whoonga" essentially does just this: exposes people to intermittent levels of single anti-HIV drugs, thus allowing HIV to develop resistance to that single agent. This has serious consequences for the drug user if they are HIV positive, and to entire communities. If an HIV positive whoonga user develops efavirenz resistance, for instance, they can then pass that resistant virus on to another person.

In resource-limited settings sophisticated drug resistance testing is often not available, further complicating the ability to identify patients who have acquired resistance through recreational HIV drug use, or from contact with a recreational drug user.

The article by Grelotti and colleagues also outlines other potential consequences: diversion of HIV drugs, criminal behavior related to HIV drug diversion that can endanger patients and healthcare providers, et cetera. These authors call for more research into this issue and enhanced screening for recreational HIV drug use by clinicians.

Using HIV Drugs for Staphylococcus aureus Infections?

Staphylococcus aureus (cdc.gov)

Here is an interesting article by Alonzo et al just published in Nature looking at the pore-forming toxin "leukotoxin ED" (LukED) secreted by many Staphylococcus aureus bacteria. Pore-forming toxins create channels in human cells that disrupt cell function and ultimately lead to cell death.

These authors found that a receptor on human T cells, CCR5, which also happens to be a co-receptor for HIV entrance into T cells, is required for LukED activity.

This is interesting in that we already have a drug (maraviroc) used to treat HIV that blocks the CCR5 receptor, thereby disrupting HIV's ability to gain entrance into human T cells. Alonzo et al found that maroviroc disrupted LukED killing of T cells in vitro. These authors used an in vivo model looking at LukED's effect on mice with and without the CCR5 receptor and found mice with the receptor were more likely to die (the implication being LukED cytotoxicity is dependent to a large extent on the CCR5 receptor). 

Not all Staphlococcus aureus isolates harbor the LukeED toxin, and it is not clear if these study findings will translate into real benefits in humans. However, Staphlococcus aureus is a major cause of morbidity and mortality globally, and the above study opens up intriguing new treatment possibilities that may aid in treating these serious infections. More research is warranted. 

HIV: Learning From Stigmatization

wikipedia.org

Here is a thoughtful piece from over at PLoS on the stigma associated with various infectious diseases, especially HIV. Despite decades of research and education, discrimination still exists for people living with HIV; Gorman cites examples of people denied employment, of HIV positive inmates being isolated from other inmates and the ban on people with HIV entering the United States that was only lifted in 2009.

She poignantly notes that discrimination leads to false beliefs about disease transmission that in turn drive the stigma associated with disease. She also notes that stigmatization is a not a phenomenon isolated to HIV, but rather has been associated with many infectious diseases throughout history. Stigmas alienate people and undermine disease detection, prevention and treatment efforts.

Gorman calls for research into what drives stigmatization, with a special focus on what we can learn from history. As the emergence of new infectious diseases is a reality of human existence, learning from the stigma associated with HIV and other infectious diseases is critical.

Vitamin D Deficiency: Related to HIV?

wikipedia.org

This is an interesting retrospective cohort study published by Sherwood and colleagues looking at vitamin D deficiency (VDD) in patients with and without HIV in a cohort of military beneficiaries; VDD was defined as having a 25-OH vitamin D level < 20 ng/mL and data were collected in the early 2000s. 165  patients with HIV were matched to controls; overall, 85% of patients were male and 61% were black. Patients with HIV were not significantly more likely to have VDD; VDD was associated with black ethnicity regardless of HIV status. Low bone mineral density (BMD) was associated with low exercise, low BMI and with alcohol use, but not with VDD. Low BMD was not associated with tenofovir or other antiretroviral exposure, although there was little tenofovir exposure in this cohort (data primarily collected in early 2000s). 

On the clinical "front lines" it is often difficult to know how aggressively one should manage low vitamin D levels in HIV positive patients: is the concomitant increase in 'pill burden' and its potential negative impact on long-term compliance worth the possible benefit to bone health? If some studies, such as this one, indicate no relationship between bone mineral density and vitamin D levels, are we treating a lab value and not the patient? If VDD and BMD are not definitively linked, why check vitamin D levels at all? Although this study is valuable it does not answer these critical questions; it would be interesting to see this study repeated in the current practice era (e.g., using modern antiretroviral agents according to current practice standards). 

HIV Prevention in Prisons & Jails

wikipedia.org

This is a thoughtful PBS piece on HIV surveillance, prevention and treatment comparing 2 systems in Washington, D.C. and Zimbabwe. The article praises recent changes at the D.C. jail that have provided improved HIV testing and treatment resources, as well as condom access and better transitions to outpatient care for prisoners leaving the facility. In contrast, the article cites a Zimbabwe study indicating 49% of prisoners engage in sexual intercourse, however, they are provided no access to condoms. This occurs because homosexuality is illegal in the country. In terms of HIV prevention efforts, not targeting sexual activity in prisons will propagate the epidemic, as 28% of the Zimbabwean inmates in this story were felt to be HIV positive. Although global efforts to both identify and treat HIV infections in prisons and jails are both necessary and laudable, basic efforts to prevent intra-facility HIV transmission (such as providing access to condoms) should also be emphasized.