Preventing smoking, lowering cholesterol, controlling blood
pressure and curing hepatitis C would greatly reduce the burden of heart
attacks, non-AIDS cancers and end-stage liver disease and kidney disease in
people living with HIV, according to an analysis of a large North American cohort, published in the journal Lancet HIV.

The study found that eliminating the traditional risk factors for these conditions would have a far greater impact than optimal HIV treatment on the incidence of the conditions, emphasising the importance of screening and management of these conditions in the lifelong care of people living with HIV.

As antiretroviral therapy has prolonged the lives of people
with HIV and greatly reduced the number of deaths from AIDS-defining illnesses,
non-AIDS conditions such as cardiovascular disease, end-stage liver disease and
cancers have become the most important causes of death in people living with
HIV in higher-income countries.

Although HIV is known to increase the risk of cardiovascular
disease and some cancers, the relative contributions of HIV-associated risk
factors and other risk factors to the development of these conditions in people
living with HIV has been unclear. As a consequence, screening for risk factors,
and interventions to reduce risk factors for these conditions, have not always
been prioritised.

NA-ACCORD brings together clinical cohorts of people living
with HIV at more than 200 sites in North America. Together, these cohorts have
followed over 180,000 patients who have attended a clinic at least twice.

This analysis of cohort participants looked at people in
care, with at least two clinic visits, between January 2000 and December 2014.
All cases of heart attack, non-AIDS defining cancer, end-stage liver disease
and end-stage kidney disease that occurred after the beginning of follow-up
were evaluated for HIV- and non-HIV-related risk factors and compared with
cohort participants in the same period who did not have a diagnosis of the

The HIV-related risk factors evaluated were low CD4 count,
detectable viral load, AIDS diagnosis and antiretroviral regimen history.

The non-HIV risk factors evaluated were smoking, elevated
total cholesterol, hypertension, diabetes, stage 4 chronic kidney disease,
statin prescription and hepatitis B or C infection. Age, sex, race and HIV
transmission risk category were also considered.

Dr Keri Althoff of Johns Hopkins University calculated the population-attributable fraction,
or the proportion of cases that would be avoided in the population if the
causal risk factor was removed. This measure captures the impact of risk
factors that may have a small individual effect but are widespread in the population, as well as risk factors that have a much greater effect but are less prevalent. It allows epidemiologists to judge
which interventions that change risk factors are likely to have the biggest
population-level impact.