People infected with HIV can now live long, healthy lives — so long as they don't have a heart attack.
Cardiovascular problems among HIV patients are emerging as the latest threat they face and a major challenge for medical experts, whose success using antiretroviral drugs to prolong patients' lives has given rise to new risks.
"When I first started taking care of patients in the 1980s they virtually would all die, but now they're living and getting complications from the disease, the most prominent of which is cardiovascular disease," said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases.
Fauci said the search is on for a consistent method to stave off heart attacks and strokes in those with HIV. A promising avenue may be adding a daily lipid-lowering drug to the mix, even in patients without the usual signs of trouble such as high cholesterol or high blood pressure.
To test the idea, the National Institutes of Health has lined up about 100 hospitals, academic centers and health facilities around the globe — including the University of Maryland and Johns Hopkins Medicine in Baltimore — to take part in a long-term study that will provide a drug known as pitavastatin to HIV patients without signs of cardiovascular disease to see if it prevents heart problems.
Pitavastatin is used routinely in heart patients to lower cholesterol and has proven safe to take with HIV medications. Doctors such as Fauci already had been giving it to their healthy HIV patients assuming it would help them not only by keeping high cholesterol at bay but by also lowering HIV-associated inflammation that can cause plaque buildup in the blood vessels.
However, there is no solid scientific evidence the statin works in healthy HIV patients, Fauci said.
The REPRIEVE trial, which stands for Randomized Trial to Prevent Vascular Events in HIV, will follow patients for an average of four years each. They will come in a few times a year for tests at participating facilities.
Hopkins hopes to recruit 75 to 100 people, and already has about three dozen in the NIH trial, one of many on HIV/AIDS by researchers there, said Jamilla Howard, a research nurse for the AIDS Clinical Trials Group and the HIV Prevention Trials Network at Hopkins. The patients will come from various health facilities in the region and get extra screening for heart disease.
Stacey Scott, a 45-year-old East Baltimore mother, didn't hesitate to enroll in the study when she learned about it from her Hopkins doctor, Dr. Christie Basseth, who has been caring for her for a dozen years.
"I have HIV and a history of heart disease in my family, and if they want to spend the four years making sure my heart is good, I'm all for it," Scott said.
She wouldn't always have been interested in taking another pill. Scott was devastated to learn she had the virus in 1994 but quickly abandoned her regimen HIV medications because they made her feel sick.
The virus soon took its toll; she developed full-blown AIDS. Considering the effect on her young son if she died and learning about a new generation of medications moved her to "straighten up."
She now religiously takes an antiretroviral drug and a study pill each morning. And though it's not always comfortable for her, she forces herself to speak to the young women in her neighborhood about the dangers of drug use and promiscuity. She said she even will show them her pill box and tell them of her brush with death.
Scott views the study as another way to help herself and others.
"This is a good opportunity," she said. "I hope it works."
The outcome could prove especially important in Maryland, where HIV cases have been dropping for years but infection rates remain among the nation's highest. There were 39,513 new diagnoses nationally in 2015 and 1,348 in Maryland, according to the U.S. Centers for Disease Control and Prevention.
There are about 1.2 million people now living with HIV around the country, though one in eight don't know. Experts say the untreated HIV not only causes harm to those infected but allows the virus to be easily spread.
About 6,700 people die from HIV and AIDS in the United States each year, making it a Top 10 killer for those age 25 to 44. Most infected people die of related problems like cancers, infections — and heart attacks.
Previous research on HIV by Dr. Matthew Feinstein, a cardiovascular disease fellow at Northwestern University Feinberg School of Medicine, showed that heart disease was being vastly underestimated in HIV patients.
The risk of a heart attack is one and a half to two times higher in an HIV patient than a healthy person. Feinstein found the virus was still having this profound affect even when it was suppressed by medications.
The affect could not be attributed to patients living longer and suffering from the same health conditions as other Americans with poor diet and exercise habits, though aging does play a role. Feinstein said it likely has more to do with chronic inflammation spurred by HIV that is harming the body's vessels.
"There seems to be an accelerated risk of developing plaque in the arteries including heart arteries," Feinstein said. "It leads to an earlier manifestation of heart disease."
Cholesterol drugs reduce cholesterol and inflammation to some extent, said Feinstein, though the degree to which it does has been debated. He said some of his other research has shown that taking a statin can lower risk when the risks of a heart attack are high, but not much when there are few risk factors. That is why many doctors do not offer the medications to younger, relatively healthy people.
That is also why the large NIH study will be useful, said Feinstein, who will be keeping tabs on the NIH study through Northwestern, which also is participating in the trial.
So will Dr. Michael Horberg, director of HIV/AIDS at Kaiser Permanente and past chair of the HIV Medicine Association. He does not normally offer a cholesterol drug to his HIV patients and said he has found that keeping HIV in check has helped with other HIV-related problems.
"HIV treatment is prevention and it improves quality of life," Horberg said.
But he said some patients have other risk factors, or didn't know they were infected with HIV until the virus had done damage to their bodies. They might benefit more from a cholesterol drug than someone without HIV might.
Horberg said he believes the NIH study could show some healthful effects of taking a cholesterol drug. If it does, he will consider prescribing them more.
"Everyone on a statin? At this point I don't think so," he said. "But it's great we're talking about it because in the 1990s when [an HIV] patient came in and they were smoking, we didn't even bother worrying about it because their life expectancy wasn't long enough. Now we get to worry about all these things."