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heart disease
May 18, 2003

Hi Dr. Young

Which hiv medications are not good for a person with a family history of heart disease? Also, I have elavated liver enzymes but do not have any hepatis (had AB vaccines and tested neg for C.). Which meds might affect the liver given my situation. My last VL was quite high---350K, cd4 runs from 550-350. Thanks!

Response from Dr. Young

Thank you for your question.

The issue of heart disease prevention among persons with HIV infection has gained increasing attention lately. Before we tackle the question about HIV medications, it is crucial to remember that HIV medication-induced changes in cholesterol is simply one part of a possible risk-reduction strategy for persons at risk for heart disease. Indeed, there is some evidence to suggest that having a chronic state of infection (i.e., uncontrolled HIV infection) might also be bad for heart disease risk.

So, on with the other stuff-- recall that the biggest modifyable single risk factor for heart disease (and other illness) is tobacco smoking. Quiting smoking will likely do more for risk reduction than any single modification to HIV medications. Similarly, diet and exercise, control of high blood pressure and diabetes also play very important factors.

Within the limited discussion of how we might mitigate elevations in cholesterol with HIV medications, it is well established that some antiretroviral medications can cause elevations in either the total, or the "bad" (or LDL) subtype of cholesterol. These include most of the current protease inhibitors (ritonavir seems to be the worst at this), stavudine( Zerit) and to a lesser extent, efavirenz (Sustiva, Stocrin). Avoidance of these medications would likely result in lesser effects on cholesterol.

It is key to remember that lowering cholesterol is not the sole basis for making medication decisions around HIV care--I'd go further to say that it is only a minor factor in my decision making, since the first objective is finding well tolerated, potent medications to prevent HIV replication, AIDS progression and death. Unless we remember this, we might be making the wrong decisions or placing the wrong disease at the top of the priority list.

Each person brings to the metaphorical decision making table with a different set of conditions and needs-- for some persons, the risk of heart disease events is similar to that of HIV (for example, the person with the strongest family histories and childhood-onset diabetes). For others, there's no obvious risk factors for heart disease, but their CD4 count is very low-- hence, their risk of AIDS is far greater than heart disease.

Hope this helps to begin to answer your question. BY

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