A presentation at IAS 2023 reviews findings from the ISCHeMiA study

Lifesaving antiretrovirals come with some downsides for people living with HIV: in some cases, they’re faced with comorbidities. For example, although highly effective in suppressing HIV, integrase inhibitor-based antiretrovirals (INSTIs), now the preferred first and second line ART regimen, have been associated with an increased risk of diabetes as well as weight gain and increased BMI compared to other therapies.

One session at IAS 2023 explored several comorbidities and what kind of interventions might make a difference. One presenter, Sherika Hanley, a family physician and lecturer at the University of KwaZulu-Natal in South Africa, shared data on a study exploring whether lifestyle changes could lower cardiovascular (CVD) risks for women with HIV. Hanley explained that women with HIV (WHIV) face an added burden of obesity and hypertension, particularly in under-resourced settings. “WHIV have higher odds of developing metabolic syndrome comprised of central obesity, elevated blood pressure, lipids and blood glucose, thereby doubling the risk of CVD compared to men,” she said. “As a result, CVD has surpassed HIV as a leading cause of death in women.”

Hanley shared findings from the ISCHeMiA study, which stands for Integration of cardiovascular disease Screening and prevention in the HIV Management plan for women of reproductive age, and assessed the effectiveness of regular screening and lifestyle modification interventions in modifying CVD risk factors in South African WHIV. 

All women in the study were between 18 and 50 years old (with a mean age of 36 years) and had been in HIV care for one year. Women in the intervention arm received a lifestyle modification advice sheet, which was emphasized at subsequent visits. Women with high BMI, hypertension, diabetes and high levels were referred to a dietitian. Women in the control arm continued their management per standard of care at the primary healthcare clinic with no intervention. Of the 372 women enrolled, there were 149 in the intervention arm and 120 in the control arm, all of African descent, and all in the township of Umlazi in KwaZulu-Natal South Africa, which has the second highest prevalence of HIV in the world. The follow-up was 32 months. 

The intervention arm advised women on dietary modifications, which included reduction of salt, carbohydrates, and high fatty kind of foods, alcohol reduction, smoking cessation, and exercise. “They were advised to exercise at least 30 minutes a day, [for example], brisk walking and including it into their work activities.”

The intervention was a modest success. Women in the intervention arm increased physical activity slightly, Hanley said, and they had a modest benefit in HDL cholesterol and blood glucose levels. HDL levels in the intervention arm improved significantly from abnormal to normal levels. However, there was no effect on obesity. In fact, BMI increased significantly—not just in the intervention arm, but in the control arm as well. Women in the control arm saw declining health—more required immediate intervention for elevated LDL cholesterol levels and many newly diagnosed with diabetes and hypertension. 

“Fifty-two percent of women referred to the dietitian actually attended qualitative analysis at one-year post enrollment, and they identified several barriers to lifestyle change, including financial limitations, work commitments, lack of social support, poor body image perception and lack of insight into CVD risk.”

While the study showed missed opportunities, “the findings encourage the continued efforts towards lifestyle interventions in the prevention of CVD in women with HIV, who are characterized by higher levels of inflammation,” Hanley said. She added that HIV services still could be the locus of CVD risk prevention, even in under-resourced settings. What’s needed, she emphasized, is a person-centered multidisciplinary approach that empowers clients. Such an approach would offer clients “the opportunity to select their own targets, profiling households and communities and creating champions and strengthening healthcare provider and user relationships. Interventions needed to be sustainable, adaptive, and culturally sensitive, with robust long-term monitoring of CVD risk.”

Larry Buhl is a multimedia journalist based in Los Angeles. He has covered HIV/AIDS and other infectious diseases for more than two decades, and also covers health and science for a variety of publications. In addition to POSITIVELY AWARE, he is a regular contributor to The Body, Everyday Health and Capital & Main. His work has appeared in USA Today, Salon, Undark, KQED, the New York Times and others.