Living Longer With HIV

By Charlotte Huff

Special to the Star-Telegram

As new drugs extend the life span of patients, the medical community re-evaluates their needs.

Martin Lane has been living with HIV for 10 years, but it's not his leading health concern. Thanks to the sophisticated AIDS drugs that emerged in the mid-1990s, the life-threatening virus in Martin's bloodhas been reduced to undetectable levels, or nearly so, in recent years.

"I don't think it's going to kill me," said Lane, 48, of Granbury. "I think it's the heart that's going to kill me, more than anything."

Lane had a heart attack three years ago, abruptly becoming flushed and nauseated one morning, unwilling to consider the worst until pain ran down his left arm. He underwent an angioplasty, clearing two of his clogged arteries. Lane blames his family history; his father had suffered a fatal heart attack just a few months before.

As people with HIV live longer, moving into their 30s, 40s and 50s, doctors say that additional health problems are arising, including arthritis, hip pain and strokes.

Sometimes the health problems may be related to the drugs. Although findings are still mixed, researchers are increasingly concerned about the tendency of some AIDS drugs to raise cholesterol and triglycerides, potentially boosting heart-attack risk. Breakdown of bone composition, generally in the hips, also is a potential drug-related concern.

As with heart worries, it's not clear if the bone changes are linked to the drugs, the virus itself or other factors, such as the patient's genetics, said Dr. Daniel Skiest, associate chief of infectious diseases at the University of Texas Southwestern Medical Center at Dallas. Several of Skiest's patients have required hip-replacement surgery.

Other problems are more of a garden-variety sort, related more to the individual's increasing age, such as cataract or hernia surgeries. Neither does it help that some people with HIV have practiced a live-in-the-moment lifestyle for years -- and some persist. Dr. Elvin Adams, who oversees HIV treatment at the Tarrant County Public Health Department, estimates that as many as 80 percent of his patients smoke.

"I say, 'Now that you are not going to die of HIV/AIDS, you need to think about what you are really going to die of,' " Adams said.

What About Transplants?

Dr. Roberto Arduino, who works full time at the Houston public hospital system's HIV clinic, recalls the days when death lists were issued each week listing the names of those who had succumbed. Now he struggles to recall more than three people out of his nearly 800-patient load who have succumbed to the virus in the previous six months.

In Adams' practice of 600 patients, usually three to five people die each year of AIDS -- roughly the number who die of smoking-related cancers. Usually, Adams says, it's because they weren't keeping up with their complicated regimen of medications. Prospects for those newly found to have the virus are good, he said.

"In terms of their HIV and AIDS, I tell them they can recover normal immune function," he said. "That they can live for an undetermined period of time."

In the past several years, Adams' patients have undergone a variety of procedures, including cataract removal, back surgery and hernia repair, that previously would not have been considered essential.

"People are doing well enough now that all kinds of conditions come out of the woodwork that need to be addressed," he said. "If you have advanced AIDS, why should you have a cataract taken out?"

Across the country, improved HIV survival also is raising a sticky ethical question for transplant centers. As more people with HIV bring their virus under control, should they be prevented from receiving lifesaving transplants?

People who get organs often have other serious underlying health conditions, such as diabetes or high blood pressure, said Dr. Michelle Roland, assistant professor of medicine at University of California, San Francisco, and one of the leading researchers in this area.

"Prior to antiretroviral [HIV] therapy, it didn't make sense to allocate a scarce resource to a group of people who weren't going to benefit from it," Roland said. "That's simply not the case anymore."

Living To See Old Age

To survive, though, people with HIV often have to take numerous medications a day, some of which can trigger debilitating side effects, including severe diarrhea and nausea. Depending upon the patient and the drugs involved, the so-called AIDS cocktail -- generally a combination of daily drugs -- also can dramatically boost lipids.

It's not uncommon for Adams to see triglyceride readings top 2,000, far above the ideal threshold of 150. And starting a lipid-lowering medication doesn't always help, he said.

There is accumulating evidence that some drugs may increase the risk of heart problems, ranging from clogged arteries to heart attacks, said Skiest. The Dallas physician pointed to a study published in the November issue of The New England Journal of Medicine, which found that the risk of heart attacks increased 26 percent for every year that people continued on the drugs. Still, he stressed, the life-extending benefits of the AIDS drugs far outweigh any potential heart risk.

Les Dennis had a series of strokes before his HIV diagnosis in 2002. But he doesn't think the AIDS drugs have helped matters. Since starting them, he's gone to the hospital twice with severe chest pain and is now temporarily off the drugs under a doctor's supervision.

"Yes, these medications are wonderful," said Dennis, a licensed vocational nurse, 56, of Fort Worth. "But the problem we face is we are taking medication that's very toxic. They tell you -- it can affect your liver, it can affect your kidneys."

Dennis has made some lifestyle changes since his diagnosis, reducing his fast-food habits and eating more fruits and vegetables.

But bad habits are hard to break.

Ray Moore, whose HIV was diagnosed six years ago, has tried numerous times to kick his smoking habit, including eight rounds of hypnosis. "I've worn the patches. I've chewed the gum," he said.

Several months ago, Moore gave up trying to quit smoking and started making efforts to exercise more. Mostly, he acknowledges that he's still getting adjusted to his new life view -- one without any definite horizon.

When his HIV was diagnosed at age 50, Moore never expected to leave the hospital. Two years ago, he was consuming more than four dozen pills every 24 hours and thought every day would be his last.

"Now my doctor tells me I'm going to live to be an old man," said Moore, chairman of Positive Voices, a consumer group for people with HIV in North Central Texas. "The big cliche is, 'What am I going to do for the rest of my life?' Because I think I've got one -- and I didn't expect that."

Making The Cut For Transplants

More than five years ago, California physician Michelle Roland was finishing her residency training in internal medicine when she met a patient with HIV who was dying of liver failure.

"It was clear that the transplant center at that time was not interested in evaluating her," said Roland, now an HIV specialist and assistant professor of medicine at University of California, San Francisco.

In the years since, Roland has joined other HIV specialists nationwide in arguing that people with controlled disease -- often to the point that their virus is undetectable based on tests -- shouldn't be denied access to an organ transplant. Roland is quick to say that she doesn't blame transplant surgeons. They simply weren't aware of the dramatically improved survival prospects for people with HIV, she says, and even raising the issue has sparked some change.

Several years ago, only a handful of centers, including University of California, San Francisco, would perform any transplant on an HIV-positive patient. Now Roland is co-investigator of a National Institutes of Health-funded study that will examine liver and kidney transplants in 275 people at 16 U.S. transplant centers. More centers wanted to join, but the funding wouldn't permit it, Roland said.

Roland and some other HIV specialists argue that as people live longer with the virus, the need for transplants will increase dramatically. People with HIV are often also infected with hepatitis C, a disease that over decades can cause liver failure. The virus itself also can cause kidney damage and potentially failure over the long haul.

"My position is that patients can be controlled with HIV and should be treated as HIV-negative," said Dr. Roberto Arduino, associate professor of medicine at University of Texas Health Science Center at Houston. "If they need organ transplantation, they should have access to the procedure."

The medical issues involved are multifaceted, including whether the transplant and related drugs aggravate the individual's HIV, as well as the overall transplant success in someone with HIV compared with people not infected with the virus.

LifeGift spokeswoman Catherine Burch Graham said that she's not aware of any transplants performed on people with HIV at the medical centers served by the organ bank, including hospitals in Houston and at Harris Methodist Fort Worth. Neither has that step been taken by the transplant programs at Baylor Health Care System, said Dr. Marlon Levy, surgical director of transplantation at Baylor All Saints Medical Center in Fort Worth.

"If the [research] data truly support this, I'm sure we and the rest of the transplant community will come along and do this," Levy said. But at this point, he said, "the transplant process is such an agony for patients waiting for organs, many dying for lack of organs, why would we broaden the potential pool of recipients?"

-- Charlotte Huff

The Path Of HIV

More than 800,000 U.S. residents are HIV-positive; an additional 40,000-some cases are diagnosed annually.

Seventy percent of HIV diagnoses occur in men. African-Americans are the hardest-hit racial group, comprising more than half of all new cases.

HIV refers to the virus that causes AIDS. But due to a sophisticated arsenal of drugs, people found to have HIV don't necessarily become sick enough to progress to full-blown AIDS.

The drugs, which appeared in the mid-1990s, are sometimes called the AIDS "cocktail" because they usually include several drug classes taken in combination. Although the side effects can be significant -- among them severe nausea and diarrhea -- the drugs are extending life spans dramatically.

-- Charlotte Huff

Source: National Centers for Disease Control and Prevention

Copyright © 2003 Knight Ridder.

This article posted January 10, 2004.