This article originally appeared on the CATIE website here.   

Une version française est disponible ici.  

All epidemiological information is approximate, based on the best available data. The data contained in this fact sheet comes from the 2011 Estimates of HIV prevalence and incidence in Canada, published by the Public Health Agency of Canada (PHAC). More information about this data source can be found in the section “Where do these numbers come from?” at the end of the fact sheet. 

The number of people living with HIV in Canada (prevalence) is increasing. 

According to 2011 national HIV estimates: 

An estimated 71,300 Canadians were living with HIV at the end of 2011. 

This represents an increase of 7,300 people (11%) since 2008. 

One quarter of people living with HIV in Canada are unaware that they have HIV. 

According to 2011 national HIV estimates: 

An estimated 17,980 people living with HIV remained undiagnosed in 2011. 

This represents 25% of the estimated number of people living with HIV.

Almost 25,000 people living with HIV have died since the beginning of the epidemic. 

According to 2011 national HIV estimates: 

By the end of 2011, an estimated 24,300 people with HIV had died due to an HIV-related illness or other cause. 

The HIV epidemic in Canada is concentrated in specific populations. 

According to 2011 national HIV estimates, people living with HIV include an estimated:

35,490 gay men and other men who have sex with men (MSM). This represents 50% of all people living with HIV in Canada. The estimate includes 33,330 men whose HIV status was attributed to men having sex with men and 2,160 men whose HIV status could be attributed to either men having sex with men or injection drug use (MSM-IDU). 

14,200 people who used injection drugs (IDU). This represents 20% of all people living with HIV in Canada. The estimate includes 12,040 people whose HIV status was attributed to injection drug use and 2,160 men whose HIV status could be attributed to either men having sex with men or injection drug use (please note that these 2,160 men are the same as those noted in the bullet point above). 

23,170 people whose HIV status was attributed to heterosexual sex. This represents 33% of all people living with HIV in Canada. Of these, 10,640 people (15% of all people living with HIV) were from a country where HIV is endemic (primarily countries in sub-Saharan Africa and the Caribbean). 

600 people whose HIV status could not be attributed to sex or injection drug use. This includes people who likely contracted HIV through blood transfusions or clotting factors, transmission from mother to child, or needle-stick injuries in the workplace. This represents less than 1% of all people living with HIV in Canada. 

6,380 Aboriginal people. This represents 9% of all people living with HIV in Canada. 

16,600 females. This represents 23% of all people living with HIV in Canada. 

The number of new HIV infections in Canada has remained stable in the past several years but is not insignificant. 

According to 2011 national HIV estimates: 

An estimated 3,175 people became infected with HIV in Canada in 2011. 

This is comparable to or slightly lower than the estimated 3,335 new infections in 2008. 

The number of new HIV infections (incidence) may be decreasing among people who inject drugs, females and Aboriginal people. 

According to 2011 national HIV estimates: 

An estimated 435 new HIV infections (14% of new infections) were attributed to injection drug use compared to an estimated 565 new infections in 2008 (17% of new infections). 

An estimated 755 new HIV infections (24%) occurred in females compared to an estimated 865 new infections in 2008 (26%). 

An estimated 390 new HIV infections (12%) occurred in Aboriginal people compared to an estimated 420 new infections in 2008 (13%). 

Aboriginal populations are over-represented in the HIV epidemic. 

Despite the decrease in new HIV infections, Aboriginal people are still over-represented in the HIV epidemic. According to 2011 national HIV estimates: 

Aboriginal people accounted for an estimated 12% of all new HIV infections in 2011 despite accounting for only 4% of the Canadian population in 2006. 

The estimated HIV infection rate among Aboriginal people was 3.5 times higher than the HIV infection rate among non-Aboriginal people. 

The number of new HIV infections (incidence) may be stable among MSM, MSM-IDU and people exposed to HIV through heterosexual sex.

According to 2011 national HIV estimates: 

An estimated 1,480 new HIV infections (47% of new infections) were attributed to men having sex with men compared to an estimated 1,470 new infections in 2008 (44%). 

An estimated 80 new HIV infections (3%) were attributed to men whose HIV status could be attributed to either men having sex with men or injection drug use (MSM-IDU) compared to an estimated 90 new infections in 2008 (3%). 

An estimated 535 new HIV infections were attributed to heterosexual sex in people from a country where HIV is endemic in 2011 (17%) compared to an estimated 540 new infections in 2008 (16%). 

An estimated 645 new HIV infections were attributed to heterosexual sex in people born in a country where HIV is not endemic, including Canada, in 2011 (20% of new infections) compared to an estimated 670 new infections in 2008 (20%). 

People from countries where HIV is endemic are over-represented in the HIV endemic.

 People from countries where HIV is endemic and whose HIV status is attributed to heterosexual exposure accounted for an estimated 17% of new HIV infections in 2011 while people born in an HIV-endemic country accounted for only 2% of the Canadian population in the 2006 census.

 The estimated new HIV infection rate among people from countries where HIV is endemic is 9 times higher than among other Canadians.

 Key definitions 

HIV prevalence—The number of people who are living with HIV at a point in time. Prevalence tells us how many people have HIV. 

HIV incidence—The number of new HIV infections in a defined period of time (usually one year). Incidence tells us how many people are getting HIV. 

Where do these numbers come from? 

All epidemiological information is approximate, based on the best available data. The data contained in this fact sheet comes from the 2011 HIV prevalence and incidence estimates published by the Public Health Agency of Canada (PHAC).  

Estimates of HIV prevalence and incidence 

National HIV estimates are produced by PHAC and published every three years. Estimates of HIV prevalence and incidence are produced by PHAC using statistical methods which take into account some of the limitations of surveillance data (number of HIV diagnoses reported to PHAC) and also account for the number of people living with HIV who do not yet know they have it. Statistical modeling, using surveillance data and additional sources of information, allows PHAC to produce HIV estimates among those diagnosed and undiagnosed. The most recent estimates available are for 2011. The next set of estimates will be available in 2015 and will pertain to the year 2014.

 Acknowledgements 

We would like to thank the Surveillance and Epidemiology Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada for their helpful comments and expert review of this fact sheet. 

References 

Public Health Agency of Canada. Summary: Estimates of HIV Prevalence and Incidence in Canada, 2011. Surveillance and Epidemiology Division, Professional Guidelines and Public Health Practice Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2012. Available at: http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/estimat2011-eng.php 

Author(s): Challacombe L

This article by Sean Hosein first appeared on the CATIE website here.

Une version française est disponible ici.

The widespread availability of potent combination anti-HIV therapy (commonly called ART or HAART) has greatly decreased deaths from AIDS-related complications in Canada and other high-income countries. The benefits of ART are so profound that doctors estimate that a 20-year-old diagnosed with HIV today who takes his or her medicine exactly as prescribed and who does not have other pre-existing health issues will likely have a near-normal life expectancy.

Unfortunately, not all HIV-positive people in Canada are benefitting from ART in a timely manner. According to the Public Health Agency of Canada, researchers estimate that about 25% of 71,300 HIV-positive people alive in Canada today are not aware of their HIV status. Moreover, a large fraction of such people, because they are unaware of their HIV status, only receives care and treatment when their immune systems are very weak.

There are many disadvantages, at both a personal and societal level, to a late HIV diagnosis, including the following:

• because the immune system is weak, improvement in overall health may be delayed despite the use of ART
• such people are prone to life-threatening infections
• the cost of care is much greater
• a person who does not know his or her status may not take steps to prevent further spread of HIV

Canada

Routine HIV testing is recommended in Canada in cases of pregnancy and blood donations. Otherwise, HIV testing is primarily done in people who are at or are perceived to be at high risk for this infection. In an editorial for an upcoming issue of the Canadian Medical Association Journal, Vancouver doctors Réka Gustafson and Julio Montaner note that risk-based testing is likely to miss “a substantial proportion of [hidden HIV infections].”

Uncovering HIV

Vancouver Coastal Health and Providence Health Care conducted a pilot project and found that 60% of HIV-positive people diagnosed late in the course of infection had previously encountered the health care system, as they had at least one of the following experiences three years prior to their diagnosis or since their last negative test:

• one lab test
• a visit to the emergency department of a hospital
• been admitted to a hospital for care

Drs. Gustafson and Montaner note that according to recommendations in other high-income countries, such as France and the U.K. and U.S., “these patients should have been offered an HIV test at these earlier encounters, without needing to raise or acknowledge a specific risk.” Moreover, public health authorities in these countries now encourage health care professionals to offer HIV testing to a broad age range of people, from teenagers to senior citizens, without taking into account risk factors.

The pilot study

As part of the Vancouver Coastal Health and Providence Health Care pilot project, hospital administrators recommend HIV testing “as part of all medical admissions and emergency department visits,” stated Gustafson and Montaner. Preliminary analysis of the pilot project found that 43% of hospital doctors offered the test and 92% of participants consented to be tested for HIV. This project uncovered six new cases of HIV infection per 1,000 tests. Other research has found that even one new case of HIV per 1,000 tests is cost effective. Based on the results from the pilot study, Dr. Gustafson, who is the Medical Health Officer for Vancouver Coastal Health, now recommends offering routine screening for HIV in hospitals and doctors’ offices.

Editorial in Canada’s medical journal

In an upcoming issue of the Canadian Medical Association Journal, based on the success of the BC pilot study, Drs. Gustafson and Montaner encourage other provinces and territories to “implement and evaluate routine HIV testing across Canada.” Hopefully such testing will be accompanied by supportive counselling both before and after testing.

This recommendation seeks to normalize HIV testing so that it is routinely done in hospitals and clinics so that undiagnosed cases of HIV can be caught early. Such normalization can help reduce costs, improve personal health and reduce the transmission of HIV.

                                                                                                —Sean R. Hosein

REFERENCES: 

Gustafson R, Montaner J, Sibbald B, et al. Seek and treat to optimize HIV and AIDS prevention. Canadian Medical Association Journal. 2012; in press.

Sabin C. Review of life expectancy in people with HIV in settings with optimal ART access: what we know and what we don’t. In: Program and abstracts of the 11th International Congress on Drug Therapy in HIV Infection, 11–15 November 2012, Glasgow, UK. Abstract O131.

May M, Gomples M, Sabin C, et al. Impact on life expectancy of late diagnosis and treatment of HIV-1 infected individuals: UK Collaborative HIV Cohort Study. In: Program and abstracts of the 11th International Congress on Drug Therapy in HIV Infection, 11–15 November 2012, Glasgow, UK. Abstract O133.

Lohse N, Hansen AB, Pedersen G, et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Annals of Internal Medicine. 2007 Jan 16;146(2):87-95.

Lohse N, Hansen AB, Gerstoft J, et al. Improved survival in HIV-infected persons: consequences and perspectives. Journal of Antimicrobial Chemotherapy. 2007 Sep;60(3):461-3.

Søgaard OS, Lohse N, Østergaard L, et al. Morbidity and risk of subsequent diagnosis of HIV: a population based case control study identifying indicator diseases for HIV infection. PLoS One. 2012;7(3):e32538.

Krentz HB, Gill MJ. Cost of medical care for HIV-infected patients within a regional population from 1997 to 2006. HIV Medicine. 2008 Oct;9(9):721-30.

Haukoos JS, Hopkins E, Conroy AA, et al. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA. 2010 Jul 21;304(3):284-92.

Palfreeman A, Nyatsanza F, Farn H, et al. HIV testing for acute medical admissions: evaluation of a pilot study in Leicester, England. Sexually Transmitted Infections. 2012; in press.

Casalino E, Bernot B, Bouchaud O, et al. Twelve Months of Routine HIV Screening in 6 Emergency Departments in the Paris Area: Results from the ANRS URDEP Study. PLoS One. 2012;7(10):e46437.

Bezemer D, de Wolf F, Boerlijst MC, et al. 27 years of the HIV epidemic amongst men having sex with men in the Netherlands: an in depth mathematical model-based analysis. Epidemics. 2010 Jun;2(2):66-79.

Audelin AM, Cowan SA, Obel N, et al. Phylogenetics of the Danish HIV epidemic: the role of very late presenters in sustaining the epidemic. Journal of Acquired Immune Deficiency Syndromes. 2012; in press.

Wilson DP, Jin F, Jansson J, et al. Infectiousness of HIV-infected men who have sex with men in the era of highly active antiretroviral therapy. AIDS. 2010 Sep 24;24(15):2420-1.

Krentz HB, Gill MJ. Impact of expanded HIV screening. Annals of Internal Medicine. 2007 Jul 17;147(2):146.

This article first appeared on the CATIE website here.

Une version française est disponible ici. 

The widespread availability of potent combination therapy (commonly called ART or HAART) for HIV has led to greatly improved health and survival for HIV-positive people in Canada and other high-income countries who can adhere to therapy.

Although ART has many benefits, it does not entirely suppress the inflammation that is incited by chronic HIV infection. Researchers are concerned that prolonged exposure to such inflammation could have an effect on many organ-systems, including the brain, particularly as HIV-positive people age.

In the time before HAART became available, HIV could cause serious impairment of intellectual functioning as well as problems with movement, muscle control, reflexes and other related issues. However, in the current era, thanks to ART, such severe HIV-related problems are uncommon. Instead, research teams have reported that mild neurocognitive impairment appears to be relatively common.

Neurocognitive dysfunction can degrade a person’s quality of life and reduce their overall potential. A decline in neurocognitive abilities could affect the speed at which information is processed in the brain. Reduced processing speed could have the following potential impacts on HIV-positive people:

• affect their ability to take ART and other medicines exactly as prescribed (adherence)
• reduce their ability to manage their finances
• weaken their attention span, which could affect their ability to read, learn and drive safely 

Researchers have found that reduced processing speed and other impairments in neurocognitive functioning also occur in older HIV-negative adults. Aging specialists (gerontologists) have developed brain-training exercises to help these adults. Such exercises are generally computer-based game-related activities that stimulate different parts of the brain and have been found to do the following in experiments with older HIV-negative people:

• improve performance of everyday tasks
• improve driving safety and significantly reduce car crashes in simulated tests 

In at least one study, HIV-negative people who have done brain-training exercises reported better overall health, improved neurocognitive function and seem to be at reduced risk of depression. 

Spurred by these promising results, a research team at the University of Alabama that included specialists in geriatric medicine, dementia and psychology conducted a pilot study of one package of brain-training exercises in 22 middle-aged HIV-positive people and compared their subsequent neurocognitive performance to that of 24 other middle-aged HIV-positive people who did not receive brain training.

Results of neurocognitive testing showed that after 10 hours of limited brain-training exercises done over a period of five weeks, participants had faster information processing. Bear in mind that this was a pilot study and although the results appear promising, there are many issues that need to be explored and resolved with regard to brain-training exercises in HIV-positive people.

Study details

Researchers carefully screened and recruited HIV-positive people without mental health conditions, brain trauma or any history of neurological damage.

The average profile of 46 participants was as follows:

•  74% men, 26% women
• age – 52 years
• CD4+ count – 450 cells
• proportion prescribed ART – 95%
• proportion with an HIV viral load less than 50 copies/ml – 30% 

Researchers randomly assigned participants to one of the following two groups:

• 22 participants entered the brain-training group
• 24 participants acted as a control or comparison group and did not receive brain training 

Once randomized, participants returned to the study centre and were told how to do the brain-training exercises. The 10 hours of brain training could be done over a period of several weeks.

Participants used a program called Insight, made by the Posit Science Company. They used games that were designed to speed up information processing.

All participants were interviewed at the start and at the end of the study and at both time points underwent neurocognitive testing.

Those participants who did not receive brain training were contacted five weeks after randomization to schedule neurocognitive testing.

Results 

At the start of the study, there were no significant differences between study groups.

Researchers found that participants who underwent brain training showed improved ability to carry out everyday activities. However, improvements to higher brain functions such as those involving planning, memory, reasoning ability and problem solving did not occur. Yet, when interviewed on completion of brain-training exercises, participants felt that they experienced improvements in the following areas:

• overall mental ability
• memory
• speed of information processing
• ability to focus

Bear in mind

1. The results from this pilot study are encouraging; however, it was just a pilot study.
2. Only one neurocognitive aspect—speed of information processing—was targeted by the brain-training exercises.
3. Although ART was prescribed to 95% of participants in the present study, rates of response to therapy were relatively low, as judged by the proportion (30%) of participants who had a viral load less than 50 copies/ml.

It is likely that HIV-positive people who are working in demanding fields and whose work requires analytic abilities and higher mental functions may be better served by exercises that are designed to focus on a variety of neurocognitive functions, including the following areas:

• memory
• reasoning
• vocabulary
• numeracy

Moving forward

In the future, other studies should consider these issues when researching brain training in HIV-positive people:

• confirm the present study’s findings
• assess how long the benefits of such brain-training exercises last
• determine how much brain training people need
• use more sophisticated and complex brain-training exercises so that higher intellectual functions can be restored, maintained or improved
• compare the effects of different brain-training software on HIV-positive people
• explore whether specific combinations of anti-HIV drugs affect the response to brain training

The Alabama research team stated that other interventions might also be useful for improving neurocognitive functioning in HIV-positive adults, specifically these:

• physical exercise
• intellectual stimulation
• improved nutrition
• better sleep hygiene
• reduced alcohol and substance use
• treatment of depression and other mental health issues

However, the researchers noted that these interventions also require testing to assess their impact on HIV-positive people’s neurocognitive abilities.

Resources

A mind of her own – understanding HIV and how to deal with neurocognitive issues

HIV and cardiovascular disease – CATIE Fact Sheet on tips for a healthy heart. 

                                                                                                     Sean R. Hosein

REFERENCES:

 1. Vance DE, Wadley VG, Crowe MG, et al. Cognitive and Everyday Functioning in Older and Younger Adults with and without HIV. Clinical Gerontologist. 2011 Oct;34(5):413-426.

 2. Vance DE, Fazeli PL, Ross LA, et al. Speed of processing training with middle-age and older adults with HIV: a pilot study. Journal of the Association of Nurses in AIDS Care. 2012 Nov;23(6):500-10.

 3. Appay V, Sauce D. Immune activation and inflammation in HIV-1 infection: cause and consequences. Journal of Pathology. 2008 Jan;214(2):231-41.

 4. Gendelman HE, Zheng J, Coulter CL, et al. Suppression of inflammatory neurotoxins by highly active antiretroviral therapy in human immunodeficiency virus-associated dementia. Journal of Infectious Diseases. 1998 Oct;178(4):1000-7.

 5. Harezlak J, Buchthal S, Taylor M, et al. Persistence of HIV-associated cognitive impairment, inflammation, and neuronal injury in era of highly active antiretroviral treatment. AIDS. 2011 Mar 13;25(5):625-33.

 6. Griffin ÉW, Mullally S, Foley C, et al. Aerobic exercise improves hippocampal function and increases BDNF in the serum of young adult males. Physiology & Behavior. 2011 Oct 24;104(5):934-41.

 7. Fabbiani M, Ciccarelli N, Tana M, et al. Cardiovascular risk factors and carotid intima-media thickness are associated with lower cognitive performance in HIV-infected patients. HIV Medicine. 2012; in press.

 8. McCrimmon RJ, Ryan CM, Frier BM. Diabetes and cognitive dysfunction. Lancet. 2012 Jun 16;379(9833):2291-9.

 9. Peters R. Blood pressure, smoking and alcohol use, association with vascular dementia. Experimental Gerontology. 2012; in press.

 10. Igase M, Kohara K, Miki T, et al. The association between hypertension and dementia in the elderly. International Journal of Hypertension. 2012;2012:320648.

 11. White WB, Wolfson L, Wakefield DB, et al. Average daily blood pressure, not office blood pressure, is associated with progression of cerebrovascular disease and cognitive decline in older people. Circulation. 2011 Nov 22;124(21):2312-9.

 12. Yaffe K, Lindquist K, Schwartz AV, et al. Advanced glycation end product level, diabetes, and accelerated cognitive aging. Neurology. 2011 Oct 4;77(14):1351-6.

 13. Heaton RK, Clifford DB, Franklin DR Jr., et al. HIV-associated neurocognitive disorders persist in the era of potent antiretroviral therapy: CHARTER Study. Neurology. 2010 Dec 7;75(23):2087-96

This article by Sean Hosein first appeared on the CATIE website here.

Une version française est disponible ici.

In the time before potent combination therapy for HIV (commonly called ART or HAART) became available one of the symptoms associated with HIV infection was persistent fatigue. In some cases, the intensity of fatigue was severe and could be disabling. This symptom was generally not linked to depression or other obvious health problems. Moreover, the reason for this fatigue was not clear but it was linked to declining CD4+ cell counts and worsening health.

It is uncertain how common HIV-related fatigue is in the modern era. Given the tremendous benefit of ART on overall health and survival, some researchers expect that HIV-related fatigue may now be less common. A team of researchers at the Royal Victoria Hospital in Newcastle-upon-Tyne in the UK have been studying fatigue in people with HIV infection and in HIV-negative people with Chronic Fatigue Syndrome (CFS) and comparing them to otherwise-healthy HIV-negative people.

The findings from their investigation with 240 participants suggest that, in the present era, fatigue is relatively common and can be severe in HIV-positive people. It appears likely that previous exposure to certain medicines may have played a role in the fatigue seen in some HIV-positive people. This exposure may have caused lasting dysfunction within part of the nervous system called the autonomic nervous system, which, in turn, led to fatigue.

Study details

Researchers recruited three groups of people as follows:

• 100 HIV-positive participants
• 100 healthy HIV-negative people
• 76 HIV-negative people who had been diagnosed with CFS

All participants completed questionnaires that had been previously validated for assessing fatigue and dysfunction of the autonomic nervous system. Also, data collected from the HIV-positive participants’ medical records was used for analysis. 

The average profile of the HIV-positive participants was as follows:

• 64% men, 36% women
• age – 47 years
• duration of HIV infection – 8 years
• current CD4+ cell count – 520 cells
• lowest-ever CD4+ count – 194 cells
• 91% were currently taking ART
•  78% of all participants had an HIV viral load of 40 copies/ml or less
• 1% of participants were co-infected with hepatitis C virus (HCV)

Results—Fatigue

Slightly more than half of the HIV-positive participants (51%) reported an excessive degree of fatigue. Moreover, 28% of HIV-positive people reported a severe degree of fatigue.

The intensity of fatigue experienced by HIV-positive participants was significant and at least threefold greater than that reported by healthy HIV-negative people.

HIV-positive people who reported the greatest intensity of fatigue had a level similar to that reported by participants with CFS.

Running on automatic

The part of the nervous system that deals with functions that can occur without conscious involvement is called the autonomic nervous system. There are many functions under the influence of the autonomic nervous system, including the following:

• blood pressure
• breathing
• heartbeat
• control of muscles such as those that are part of the anus and bladder
• sleeping
• temperature control 

One consequence of a dysfunctional autonomic nervous system can be orthostatic hypotension (OH). In OH, the following symptoms can occur:

• dizziness upon standing
• blurred vision
• reduced sense of hearing
• difficulty concentrating
• weakness 

These symptoms can have other causes, including drug side effects, so having them does not necessarily mean that a person has underlying problems with their autonomic nervous system. 

HIV and a dysfunctional autonomic nervous system 

Symptoms suggestive of dysfunction within the autonomic nervous system were common among HIV-positive participants, with 38% reporting them. Furthermore, HIV-positive participants tended to report more severe symptoms compared to healthy HIV-negative participants. 

Among HIV-positive participants, fatigue was statistically linked to the following factors—having symptoms suggestive of autonomic nervous system dysfunction and exposure to so-called “d-drugs” such as the following:

• d4T (stavudine, Zerit)
• ddI (didanosine, Videx)
• ddC (zalcitabine, Hivid)

Focus on fatigue and HIV

The research team states that “fatigue remains a very common and often severe symptom in [HIV-positive] patients.” Furthermore, they note that “it is likely that this condition is significantly under-recognized.”

The researchers were surprised at the high level of fatigue reported by participants because most had viral loads in their blood of 40 copies/ml or less. Moreover, their CD4+ counts were relatively high at about 520 cells. In the time before the widespread availability of ART, high viral loads and low CD4+ cell counts were associated with severe fatigue.

Possible fatigue factors in the modern era

The underlying cause(s) of fatigue in some ART users in the modern era is likely complex and could involve biological and psychological factors. However, none of the HIV-positive participants had untreated depression or anxiety (although the research team cannot fully exclude that some patients may have had undiagnosed depression). What might the possible biological factors be? Some clues have emerged from the present study. The researchers found that many HIV-positive participants with severe fatigue tended to have the following features:

• long-standing HIV infection
• previous exposure to d-drugs
• lipodystrophy syndrome – obvious signs of change in body shape due to the loss of the fatty layer just under the skin (particularly in the face, arms and legs) and a redistribution of fat (resulting in a large belly)

The research team was unable to assess which of these three factors had the most important bearing on fatigue because all three factors were so commonly seen together among people with fatigue.

d-drugs and their discontents

The d-drugs are now known to damage structures called mitochondria—the energy-producing parts of a cell, particularly in nerves. One d-drug, d4T, has been linked to the development of the lipodystrophy syndrome. It is therefore possible that past exposure to d-drugs may have damaged nerves and muscles, predisposing some HIV-positive people to fatigue. Certainly, in the case of HIV-negative people with CFS, other researchers using magnetic resonance imaging (MRI) have found that muscle cells may have damaged mitochondria.

Dysfunction within

Another important new finding from the UK study was the link between fatigue and symptoms suggestive of dysfunction within the autonomic nervous system.

Emerging research suggests that dysfunction within the autonomic nervous system plays an important role in perhaps inciting and intensifying fatigue in several chronic diseases, such as the following:

• multiple sclerosis (MS)
• primary biliary cirrhosis (PBC)
• CFS

In an exciting development, the UK’s Medical Research Council has recently funded several research projects to explore autonomic nervous system dysfunction and fatigue in CFS. This research may in the future help researchers better understand fatigue in other chronic conditions, including HIV (Brendan Payne, MD, personal communication).

Strengths and weaknesses

The cross-sectional nature of the present study means that its findings are not definitive. Cross-sectional studies are cheaper and less cumbersome than larger studies that run for several years. The present study did have several strengths, including its size and the fact that there were three different groups that could be compared against each other. Moreover, the research team should be praised for initiating an investigation into a subject that is difficult to study, such as fatigue.

What to do?

Lead researcher Brendan Payne, MD, suggests that physicians and nurses “actively look for fatigue in their HIV-positive patients.” Dr. Payne also suggests an integrated approach to managing this fatigue, similar to what has been proposed for patients with primary biliary cirrhosis. As part of such an approach, doctors would first perform investigations to rule out common causes of fatigue. In HIV infection this would likely include assessments for anemia, diabetes, dysfunction of the thyroid gland, depression, less-than-normal levels of testosterone, co-infections, deficiencies of vitamin B12 and other nutrients, sleep disturbances and so on.

In clinical trials of the treatment of HIV-related fatigue, researchers in the U.S. have found that the drug modafinil (Provigil) and its analogues (armodafinil, Nuvigil) can sometimes provide relief.

Acknowledgement

We thank infectious disease specialist Brendan Payne, MD, for his research assistance, helpful discussion and expert review.

REFERENCES:

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 2. Kaslow RA, Phair JP, Friedman HB, et al. Infection with the human immunodeficiency virus: clinical manifestations and their relationship to immune deficiency. A report from the Multicenter AIDS Cohort Study. Annals of Internal Medicine. 1987 Oct;107(4):474-80.

 3. Darko DF, McCutchan JA, Kripke DF, et al. Fatigue, sleep disturbance, disability, and indices of progression of HIV infection. American Journal of Psychiatry. 1992 Apr;149(4):514-20.

 4. Hollingsworth KG, Newton JL, Taylor R, et al. Pilot study of peripheral muscle function in primary biliary cirrhosis: potential implications for fatigue pathogenesis. Clinical Gastroenterology and Hepatology. 2008 Sep;6(9):1041-8.

 5. Robinson-Papp J, Simpson DM. Neuromuscular diseases associated with HIV-1 infection. Muscle and Nerve. 2009 Dec;40(6):1043-53.

 6. Jong E, Oudhoff LA, Epskamp C, et al. Predictors and treatment strategies of HIV-related fatigue in the combined antiretroviral therapy era. AIDS. 2010 Jun 19;24(10):1387-405.

 7. Niepel G, Bibani RH, Vilisaar J, et al. Association of a deficit of arousal with fatigue in multiple sclerosis: Effect of modafinil. Neuropharmacology. 2013 Jan;64(1):380-8.

 8. Al-Harthy N, Kumagi T, Coltescu C, et al. The specificity of fatigue in primary biliary cirrhosis: evaluation of a large clinic practice. Hepatology. 2010 Aug;52(2):562-70.

 9. Abbas G, Jorgensen RA, Lindor KD. Fatigue in primary biliary cirrhosis. Nature Reviews. Gastroenterology & Hepatology. 2010 Jun;7(6):313-9.

 10. Jones DE, Hollingsworth KG, Taylor R, et al. Abnormalities in pH handling by peripheral muscle and potential regulation by the autonomic nervous system in chronic fatigue syndrome. Journal of Internal Medicine. 2010 Apr;267(4):394-401.

 11. Kanjwal K, Karabin B, Kanjwal Y, et al. Autonomic dysfunction presenting as postural orthostatic tachycardia syndrome in patients with multiple sclerosis. International Journal of Medical Sciences. 2010 Mar 11;7:62-7.

 12. Kanjwal K, Karabin B, Kanjwal Y, et al. Autonomic dysfunction presenting as orthostatic intolerance in patients suffering from mitochondrial cytopathy. Clinical Cardiology. 2010 Oct;33(10):626-9.

 13. Hollingsworth KG, Newton JL, Robinson L, et al. Loss of capacity to recover from acidosis in repeat exercise is strongly associated with fatigue in primary biliary cirrhosis. Journal of Hepatology. 2010 Jul;53(1):155-61.

 14. Jones DE, Sutcliffe K, Pairman J, et al. An integrated care pathway improves quality of life in Primary Biliary Cirrhosis. Quarterly Journal of Medicine. 2008 Jul;101(7):535-43.

 15. Rabkin JG, McElhiney MC, Rabkin R. Modafinil and armodafinil treatment for fatigue for HIV-positive patients with and without chronic hepatitis C. International Journal of STD and AIDS. 2011 Feb;22(2):95-101.

 16. Rabkin JG, McElhiney MC, Rabkin R. Treatment of HIV-related fatigue with armodafinil: a placebo-controlled randomized trial. Psychosomatics. 2011 Jul-Aug;52(4):328-36.

This article first appeared on the website of CATIE here. 

Une version française est disponible ici. 

Surveys have found that tobacco use is common among some HIV-positive people. As much as 40% of some clinic populations have been found to smoke cigarettes. In the time before potent combination anti-HIV therapy (commonly called ART or HAART) became widely available, smoking cessation was not a major concern for HIV-positive people and their health care providers.

In the present era, researchers increasingly expect ART users to have survival rates broadly similar to those of HIV-negative people. However, there are increasing reports of shortened survival among some HIV-positive people due to complications arising from cancers, co-infections and cardiovascular disease. Smoking tobacco elevates the risk for cancers, heart attack and other complications, ultimately worsening quality of life and decreasing lifespan. In one international study of more than 5,000 HIV-positive people, researchers estimated that smoking tobacco was either directly or indirectly responsible for 24% of the deaths that occurred over the long term.

Help for quitting

Concerned about the harmful impact of smoking and trying to improve ways to help HIV-positive people quit, researchers at the Albert Einstein College of Medicine in the Bronx, New York, have been conducting studies related to this issue. Their latest study was a randomized controlled trial comparing an intensive group therapy–centered approach to standard advice about quitting.  All participants were offered nicotine replacement therapy. Participants who received intensive group therapy–based support had nearly double the quit rate after three months.

Furthermore, the researchers found that two factors—loneliness and participants’ confidence in their ability to resist the urge to smoke—were significantly associated with their ability to break free from smoking. The results of this and other studies should encourage clinicians to refine their tobacco-cessation programs for HIV-positive people.

Study details

Participants in the study were randomly assigned to either enter the intensive program, called Positive Smoke Free (PSF), or receive brief standard counselling. Within the PSF program, participants were divided into small groups of six to eight people. Each group was led by two facilitators, one was an HIV-positive peer and the other was a graduate student of a psychology program. Both facilitators had training about tobacco addiction.

Focus on PSF

PSF is an eight-session intervention based on the Tobacco Dependence Treatment Handbook. The PSF program was created by making modifications to the work in the handbook, so that the concerns of HIV-positive people could be incorporated. These concerns, identified in pilot studies, included the following:

• specific risks of smoking for HIV-positive people
• co-existing mental health and emotional issues
• substance use
•  social isolation
• stress reduction

Each group had a weekly 90-minute session. Key issues covered in these meetings including the following:

• reviewing the many health risks associated with exposure to tobacco smoke
• dispelling myths about the alleged benefits of smoking
• exploring self-discipline and delaying instant gratification and their impact on improved health
• understanding the importance of adherence
• understanding and enduring temporary discomfort in exchange for long-term health
•  assertive training to negotiate HIV care
• dealing with urges to skip medical appointments or doses of HIV medications
• understanding the link between HIV, pain, tobacco use and quitting
• remaining free from tobacco over the long-term

Smoke-free status was confirmed by the evaluation of the exhaled air of participants for carbon monoxide at several points throughout the study.

Of the 184 people who volunteered for the study, 147 made it through the screening process and were randomly assigned to one of the following groups:

1. 73 participants – PSF
2. 72 participants – so-called standard therapy, consisting of a brochure about quitting, brief advice (less than five minutes) about quitting and free nicotine replacement therapy if they wished 

The average profile at the time participants entered the study was as follows:

• gender – 50% women, 49% men, 1% transgendered
• age – 48 years
• CD4+ count – 500 cells
• housing status – 90% had stable housing status
• employment – 89% were unemployed

HIV infection risk factors included the following:

• unprotected heterosexual sex – 58%
•  unprotected sex between men – 15%
• injection drug use – 15%
• contaminated blood transfusion – 3%

Commonly used substances in the month prior to enrollment in the study were as follows:

• marijuana – 42%
• cocaine – 29%
• heroin – 8%

Most people had been smokers for more than 30 years, consuming an average of 12 cigarettes daily.

Results

Overall, 21 participants (15%) were able to quit after the three-month program ended, distributed as follows:

 • PSF – 19%

 • standard therapy – 10%

Although the outcome of this study is highly promising and likely clinically meaningful—nearly twice as many PSF participants quit—the difference in quit rates did not reach statistical significance.

The study team assessed possible reasons that might have influenced people to quit, including the following:

• group facilitators – a comparison of different group leaders did not find any impact on outcomes
• prescribed medicines – although 40% of participants received nicotine replacement  therapy or other prescribed drugs, such as bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix), to help ease the path to quitting, prescribed medicines on their own did not apparently affect quit rates in this study
• race/ethnicity – people of Latino ethnicity were more likely to quit
• loneliness – people who were lonelier were less likely to quit

Improvements to the next clinical trial

The PSF program was clearly advantageous in helping people to quit. Researchers found that quit rates were significantly greater among PSF participants if they attended seven or more counselling sessions and also received prescribed therapy to help them quit. Keeping people motivated in any clinical trial is not easy, particularly in trials of smoking cessation. Future trials should consider prescribed medicines for smoking cessation as well as ways to maximize attendance at support group meetings. Additional considerations include the following:

Race/ethnicity – Researchers are not certain why Latino participants were more likely to quit smoking in the present study. They found that Black people were less likely to quit and so more research is needed to understand these issues concerning race and ethnicity.

Loneliness – Past research has found that loneliness is linked to an increased risk for tobacco use. Perhaps this may be related to boredom and stigmatization, which are also related to the use of tobacco. The social aspects of the PSF program were the most appreciated part of the program by participants. This finding may be useful for future studies.

The present study has produced highly promising results and shows that smoking cessation is possible among HIV-positive people who are motivated to quit. Perhaps future studies should be of a longer duration, both to provide more social support for participants and to assess how long they are able to remain smoke free.

Resources:

 •CATIE-News: Understanding Tobacco Addiction

 • Canadian Cancer Society: Smoking and tobacco

 • Canadian Lung Association: Smoking & tobacco

 • Santé et services sociaux Québec: Tobacco and your health

 • CATIE: Up in Smoke - The ifs, ands or buts of butting out

 • CATIE Factsheet: HIV and Cardiovascular disease

                                                                                                                        —Sean R. Hosein

REFERENCES:

 1. Gong J, Hutter CM, Baron JA, et al. A pooled analysis of smoking and colorectal cancer: timing of exposure and interactions with environmental factors. Cancer Epidemiology, Biomarkers & Prevention. 2012; in press.

 2. Fabbiani M, Ciccarelli N, Tana M, et al. Cardiovascular risk factors and carotid intima-media thickness are associated with lower cognitive performance in HIV-infected patients. HIV Medicine. 2012; in press.

 3. Shuter J, Bernstein SL, Moadel AB. Cigarette smoking behaviors and beliefs in persons living with HIV/AIDS. American Journal of Health Behavior. 2012 Jan;36(1):75-85.

 4. Moadel AB, Bernstein SL, Mermelstein RJ, et al. A Randomized Controlled Trial of a Tailored Group Smoking Cessation Intervention for HIV-Infected Smokers. Journal of Acquired Immune Deficiency Syndromes. 2012 Oct 1;61(2):208-215.

 5. Lifson AR, Neuhaus J, Arribas JR, et al. Smoking-related health risks among persons with HIV in the Strategies for Management of Antiretroviral Therapy clinical trial. American Journal of Public Health. 2010 Oct;100(10):1896-903.

 6. Lauder W, Mummery K, Jones M, et al. A comparison of health behaviours in lonely and non-lonely populations. Psychology, Health, and Medicine. 2006 May;11(2):233-45.

This article first appeared on the website of CATIE  here.  

Une version française est disponible ici. 

Recent advancements in our understanding of HIV transmission, treatment, prevention and testing are changing the landscape of our response to HIV and generating a significant amount of optimism. The buzz at the International AIDS Conference this past July in Washington D.C. was that we may now be able to achieve an ‘AIDS-free generation’ where first, no one will be born with the virus; second, that as people age, they will be at a far lower risk of becoming infected than they are today; and third, that if they do acquire HIV, they will get treatment that keeps them healthy and prevents them from transmitting the virus to others.

Similarly, the United Nations AIDS organization has launched a ‘Getting to Zero’ campaign for this World AIDS Day, December 1, signifying the aim of getting to zero new infections, zero AIDS-related deaths, and zero discrimination.  

There are many reasons why we should feel these commendable goals can be achieved. But there are also significant challenges that need to be addressed before we get there.

New understanding about HIV

First, a word about those things that give us confidence.

We now have newer medications for people living with HIV that are easier to take and have fewer side-effects, thereby making HIV treatment more manageable. These medications also allow people living with HIV to have a near-normal life expectancy. We also have a much better understanding of the importance of starting treatment earlier in order to achieve better health outcomes.

Treatment can also help prevent the transmission of HIV. Research shows that people living with the virus who are on successful antiretroviral therapy and have a fully suppressed viral load (undetectable) are less likely to pass HIV onto others.

Due to these advancements in our understanding of the virus, treatment guidelines now recommend that people living with HIV begin antiretroviral therapy as soon as they are ready after diagnosis.

The importance of early detection

To complement the uptake of early treatment, we have also made progress in developing new testing technologies and strategies that allow us to detect HIV earlier and faster than ever before, allowing HIV-positive people to learn about their status much sooner after becoming infected. 

Early diagnosis is crucial to our success in preventing HIV transmission for three major reasons.  First, it may help identify people during the first few months after HIV infection when their viral load and risk of HIV transmission is at an all-time high. Second, it gives newly diagnosed individuals the option to start treatment earlier. And lastly, the majority of people diagnosed with HIV take active measures to reduce their risk of passing HIV on to others.

New prevention approaches

Although condoms and clean needles are the backbone of our prevention efforts, we are learning about additional prevention tools that can also be used. We now know that the same drugs used to treat HIV can be used by HIV-negative people to help reduce their risk of an HIV infection. These preventative approaches are known as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP). While PEP is the standard of care for occupational exposure to HIV, its availability for non-occupational exposures and its cost vary greatly across Canada. Although PrEP is not currently approved for use by Health Canada, some doctors may already be prescribing it to their patients (known as ‘off-label’ use).These new prevention approaches are promising options for HIV-negative people who are at a high risk of getting HIV.

HIV drugs, in combination with other strategies such as not breastfeeding can also help eliminate the transmission of the virus from an HIV-positive mother to her newborn child.

Challenges we still face

Despite these advancements, translating them into a generation without AIDS or without new HIV infections remains challenging. The hurdles we continue to face include limited financial resources applied to HIV prevention and treatment, and the barriers people living with and at-risk of HIV face when accessing HIV-related services.

Additionally, people living with HIV can be criminally prosecuted for not disclosing their HIV status to their sexual partners, which can discourage them from wanting to know their status, and thereby opting out of getting tested.

Stigma, discrimination, and poverty can make it difficult for marginalized populations to access services, which explains why some populations are more strongly affected by the HIV epidemic. The reality is that a number of Canada’s communities have a high prevalence of HIV. According to the latest estimates (2008) by the Public Health Agency of Canada, gay men and other men who have sex with men represent a majority (51 per cent) of people living with HIV. People who use injection drugs represent 20 per cent, people from regions where HIV is endemic (such as Africa and the Caribbean) represent 14 per cent, and Aboriginal people represent eight per cent of the total HIV epidemic in Canada.  

Where do we go from here?

It’s clearer than ever that HIV prevention, testing, care and support, and treatment are all mutually reinforcing elements of an effective response to realizing an ‘AIDS-free generation.’ At CATIE, we feel these advancements call for an ‘integrated approach’ to HIV treatment and prevention. Such an approach will be discussed, for example, in September, 2013, when CATIE will host a forum that will explore the recent developments in HIV and determine ways to integrate HIV treatment and prevention for us to move forward in an effective way.

While we are still years away from an ‘AIDS free generation,’ we appear to be on the right path. It only takes a look back 30 years ago at the despair we once felt in the face of this unknown disease to see how far we’ve come.