Africa: Getting old on ARVs

Plusnews
Published in HIV/AIDS News by LearnScapes, issue 296
09/05/2008

Johannesburg – "Eish, with ARVs [antiretrovirals], you get fat and you get old," a patient at a Johannesburg hospital recently told her doctor. A few years ago, when people infected with HIV in the developing world were wasting away and dying in devastating numbers, her complaint would have been cause for celebration. But as more and more HIV-positive Africans extend their life expectancy with ARVs, their waistlines and risks of contracting serious non-AIDS related illnesses, such as diabetes and heart disease, are expanding accordingly.

The fourth most common cause of death in HIV-positive South Africans is now hypertension; diabetes comes in at number six. Data from the developing world on ageing with HIV are still scarce, but in the developed world only 8 percent of HIVpositive people on ARVs die of AIDS-related illnesses. "HIV might become the ultimate lifestyle disease," Dr Francois Venter, director of the Southern African HIV Clinicians Society, told their monthly meeting in Johannesburg on Thursday.

As HIV becomes an increasingly manageable chronic disease, Venter attempted to answer the question of how to help people living with the virus enjoy a relatively healthy old age. HIV-positive people may be at greater risk of certain illnesses associated with old age, and there is some evidence to suggest they may contract them sooner, but Venter was upbeat about their chances of preserving a good quality of life into old age, providing they exercised, watched their diets and avoided stress.
"The same advice we give to HIV-negative people is important for positive people," said Venter. "There's only one additional step - viral suppression [with ARV medication]."

Venter advised his fellow clinicians to pay particular attention to risk factors like obesity, smoking and depression in their HIV-positive patients, and to consider the "context for care": the extent to which factors like poverty or mental health might affect the wellbeing of their patients.

He dismissed "conventional thinking" that side effects resulting from antiretroviral therapy (ART) would eventually drive mortality in people living with HIV, but another clinician in the audience commented that "the jury is still out" on what the long-term impact of ART might be on their health.

A study from Denmark has estimated that currently available ARV drugs, which are much less toxic and cause fewer side effects, can add 39 years to the life of a 25-year-old. But no such studies have been done in Africa, where environmental factors like poverty and the high prevalence of dangerous opportunistic infections, including tuberculosis, could shorten an HIV positive person's lifespan in spite of ARVs. Africans also tend to start ARV treatment much later than their European and American counterparts - the average CD4 cell count [which measures the strength of the immune system] for South Africans starting ART is between 80 and 100 – a factor that has been linked to a greater risk of contracting AIDS-related illnesses in the short term as well as non-AIDS-related illnesses in the long term. Reaching a very low CD4 count can cause permanent damage to the immune system and some internal organs, making patients particularly susceptible to liver disease, kidney failure and certain cancers. Treatment guidelines in most countries, although not in South Africa, now recommend starting patients on ART when their CD4 count drops below 350.

In South Africa, as in the rest of sub-Saharan Africa, by far the greatest risk factor for people living with HIV is not being able to get ARVs. Venter noted that less than half of South Africans in need of ARV treatment were receiving it. Partly this is due to low rates of HIV testing, but large numbers of patients still die while waiting to begin treatment.