Elevated (liver) concerns

I have heard that inflammation plays a large role in the overall damage that HIV causes and I've read that doctors can order some sort of test for "markers" of inflammation. Should I be asking my doctor to order those tests? And which ones should be done?

-Lindsey
Jacksonville, FL

Dear Lindsey,

You are correct in that inflammation is the new buzzword when discussing the effects of HIV infection. Inflammation is part of the body’s response to infection, and it is now known that fighting a long-term chronic infection like HIV throws the immune system into a chronic inflammatory state. HIV activates the immune system when it reproduces. The resulting chronic inflammation is only partially corrected by your HIV medicines. This chronic inflammation contributes to many illnesses that complicate HIV disease, including cardiovascular disease, diabetes, chronic kidney disease, osteoporosis, and cancer. These same illnesses now account for a great deal of illness and death in people living with HIV. Evidence suggests these illnesses occur more often and/or at a younger age in people living with HIV due, at least in part, to chronic inflammation.

Inflammation is part of the processes that repair and defend against damage to bodily tissue. For instance, it has been known for quite a long time that atherosclerosis (hardening of the arteries) is the result of an inflammatory response to injury. Blood vessels are damaged by high blood pressure, high blood sugar, cholesterol, smoking, etc.—and the body produces inflammation in an attempt to repair the vessel wall. However, since the damage continues—unless we are able to reduce our blood pressure, blood sugar levels, cholesterol, etc.—the inflammation persists and becomes chronic. The problem is that inflammation, which begins as a healing mechanism, eventually has the opposite effect. It causes more damage to the vessel. The accumulating damage leads to atherosclerosis: The blood vessels stiffen and thicken due to the build-up in the walls of fatty clots called plaques. These plaques contain cholesterol as well as large numbers of immune cells, including T-cells, macrophages, and something called “foam cells.”

You may have also heard of the SMART study that looked at structured treatment interruptions of antiretroviral therapy. It was found that those people who were on interrupted therapy had increased complications and death due to non-HIV related conditions such as cardiovascular and kidney disease. It is felt that the increased inflammation due to HIV replication was the cause, and consequently the study was stopped. Further tests of the blood of those patients who had their therapy interrupted have shown increased levels of certain inflammatory markers, including C-reactive protein (CRP), D-dimer, and interleukin (IL) 6.

Even though some of these markers can be checked in routine practice, we don’t yet fully understand what they mean—and whether or not they indicate if we should do anything differently for a patient’s treatment. The important thing for any HIV patient right now is to keep the viral load as low as possible, and also to quit smoking, control blood pressure, get exercise, and keep cholesterol and diabetes (if applicable) in check to minimize inflammation. Stay tuned—you will be reading more about inflammation in HIV disease, and there may eventually be tests that we can run and possibly even certain things we can do to better control inflammation in the context of HIV.

Donna E. Sweet, MD, chairs the Board of Directors of the American Academy of HIV Medicine. She is professor of Internal Medicine at the University of Kansas School of Medicine, and has a clinical practice in Wichita.

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