An Interview With David Alain Wohl, M.D.
Messaging the Findings for HIV-Positive Patients
For patients who are growing older with HIV, is this something that they should be worried about? Or is the risk not as significant as the headlines might make them seem?
I think that the risk has to be put into perspective. Again, plaques were pretty common here. There were a lot of lifestyle factors that were accounted for, but they couldn't account for everything. We don't know that the HIV-positive men are bearing increased burden of these vulnerable plaques strictly because they're HIV positive. There's a signal for that, but, you know -- cocaine use wasn't looked at [for instance]. I don't know what cocaine does to creating vulnerable plaques versus calcified plaques.
There are other things that are very hard to measure. That's been my mantra, almost to the point of annoyance: You can't correct for a lot of these other things because they're not measured, and we don't know what the effects are.
Is there an effect of HIV itself? There may be a co-inflammation thing that may tie into this. But it wasn't such a huge, profound difference. The difference was seen in much older men more than middle-aged and younger men. I think there's more that has to be done. It's certainly important.
What can men do? You said "worry." That's the one thing they shouldn't do. And I worry about studies like this, that contribute to worry. You can only change the things you can change, and you can't change the things you can't change. So, change the things you can change.
What can you change? Many of the people who are listening to this are already doing it. They're exercising. They don't smoke. They don't smoke marijuana -- again, not measured in this study. They don't do cocaine. They eat fairly healthy diets. Those are the types of things any of us have to do. I have to believe that that helps ameliorate some of the excess risk that may -- capital M-A-Y -- be related to living with HIV.
There are studies that, at the HIV conference we went to just about a month ago, showed that exercise does seem to be beneficial. I don't think that this [MACS data] would change me from doing anything else that I do when I talk to patients about living a healthy lifestyle. You can't get rid of the HIV right now, and until we do, there's nothing else I think you can do than just the normal things that we all have to do to try to prevent ourselves from having any plaque in our heart, let alone vulnerable plaque.
Clarifying Risk: CD4 Count and HIV Treatment Duration
What about the two results that they found with lower CD4 counts and people who have been on treatment longer being associated with the higher risk?
Associations with low CD4 cell count and being on therapy longer: Those are also markers for being older and living with HIV a longer period of time, and being infected longer ago. Again, it's hard to tease those out from the effects of: If you're 25 years old, you haven't been alive long enough to be someone who's had HIV for 30 years. But if you're 68 years old, you certainly could be someone who's been living with [HIV that long].
So: It's a marker for age; it's a marker for drug exposure; it's a marker for being around [during a time when more people] were doing crack cocaine, or doing powder cocaine, or living a hard life. I'm talking in general terms, because we're talking about a large dataset here. I think we have to be careful about some of these associations.
It does play into this idea that low CD4 cell count and prolonged HIV infection increase exposure to inflammation over a longer period of time. Inflammation has been associated with atherosclerotic disease and other end-organ diseases. If you drink the Kool-Aid on this, you may say that there is this Axis of Evil of immune activation, of inflammation, and then end-organ disease.
I think that's part of it. I just don't understand completely how big a part of it. This study, again, helps us understand that there are differences between HIV positive and HIV negative [in terms of plaque], but I am impressed by how the difference is modest. It wasn't like you're at 3, 4, 5, 10 times the risk of these bad plaques if you were HIV positive. But I do think it's important to pay attention to this and try to find out pathologically what's going on here.
As a provider, what would you say to a patient who is already on the fence about starting treatment, sees a study like this, and decides not to start treatment as early as he or she should?
I think people who are infected and don't want to start treatment are crazy, unless they have a fantastically good reason not to start therapy -- like, it's going to cost them $1,500 a month. And then it becomes my problem, because I have to figure out how to get them their medicines. But there's no reason.
The only [other] reason I could see that you don't start medicine is you're an elite controller, your viral load is undetectable and your T-cell count is 900. Then we can have the conversation. As you get closer and closer to that, I understand more of your ambivalence. If you have a T-cell count that's 1,000 and your viral load is 500, I could still maybe be talked into having a debate about it.
But I am a strong believer that if you're infected, you should be on therapy; that the benefits of therapy outweigh the risks; and that, again, the problems that we see with ongoing HIV replication and end organs are not a good thing. We should treat it. If I was infected and I had a CD4 cell count of 1,000 and a viral load of 30,000, I would start on HIV medicine.