Your lifestyle and physical health

Thanks to the development of effective and well tolerated treatment, HIV is now a manageable health condition with life expectancy for the majority of people being equal to that seen in the general population. Research and clinical evidence are continually evolving to provide a better understand the impact HIV can have on your physical health and wellbeing. Large scale well-designed studies have identified some key areas to focus upon when it comes to improving health outcomes and importantly enabling people to live well with HIV.

What is the link with HIV and other health conditions?

We’re constantly learning more about HIV as a long-term health condition and the links with other health conditions (co-morbidities) which include heart, cardiovascular, liver and kidney disease together with some cancers. It remains a complex subject, with current research focussing on immune activation and dysregulation. Lifelong drug therapy may also play a part in the development of some co-morbidities.

Immune activation

• Even when viral load is undetectable the immune system has to work harder than it would without HIV. This is sometimes referred to as immune activation, or more commonly inflammation. We usually associate inflammation with infection or injury to the body, which causes swelling, redness, tenderness and increased temperature in the affected area. This short lived, acute inflammation is an essential part of the immune system responding to an infection or injury
• Inflammation associated with HIV is more subtle in the way it can affect the body and is considered to be long-term and therefore referred to as chronic inflammation. HIV isn’t the only health condition which causes chronic inflammation. Others include diabetes, rheumatoid arthritis, psoriasis, asthma and inflammatory bowel disease. Chronic inflammation can damage healthy cells, tissues, and vital organs over time. HIV related inflammation can have an impact on heart and cardio-vascular health, and also that of the liver, kidneys and lungs

Immune dysfunction

• Maintaining undetectable viral load enables the immune system to function at near normal levels for the majority of people, which is demonstrated by the increases seen in life expectancy over the decades. Despite this, some people living with HIV have an increased risk of developing certain cancers which are often caused by viruses including the Human Papilloma Virus (HPV) Hepatitis B and C and Epstein Barr Virus (EBV) which is linked to the development of some forms of lymphoma
• Immune dysfunction can lead to a reduced immune response to some viral infections. When left undiagnosed and untreated these can cause cellular dysfunction leading to internal scarring of organs such as the liver, and cell abnormalities within structures and tissues which include the mucus membranes associated with the cervix, anus and throat. HIV may also play a role in reducing the effectiveness of the immune system to find and recognise damaged cells that are becoming cancerous. This reduced surveillance means the immune system isn’t able to clear these cells which allows cancer to develop over time

Adverse effects of treatment

• Modern treatment has improved tremendously since effective triple therapy was developed in the mid to late 90’s. Treatment is very effective, potent at lower doses, and has fewer on-going side effects for the majority of people. We now have a better understanding of the long-term impact drugs used to treat HIV can potentially have on the body. This, together with good levels of monitoring means HIV treatment has a good safety record, leading to fewer health complications
• There are some drugs which are associated with particular health problems. These can include an increase in cholesterol and/or triglyceride levels (blood fats), changes to kidney or liver function, and changes to bone health. It’s important to stress that serious treatment related complications are rare. With good monitoring and care they can be identified early on and changes made to prevent further complications arising

Which co-morbidities should I be aware of?

As with the general population, there are many variables which will influence the development of particular co-morbidities. People living with HIV can significantly influence their future health by making modest changes to diet, activity levels, alcohol consumption, and taking steps to reduce substance use. Smoking is by far the most important change anyone can make to reduce the risk of developing one or more of the following co-morbidities:

Heart and cardiovascular health

Bone health

Kidney health

Liver health

Lung health

Cancer risk

It’s important to stress that study data looks at groups of people and cannot accurately assess individual risk of developing the co-morbidities listed. This has to be assessed on an individual basis and is an area which HIV clinic teams are becoming more focused upon.

Regardless of how long you’ve been living with HIV it’s never too late to make some positive changes which can help safeguard your health, meaning you can enjoy a good quality of life well into older age.

Your daily activity levels

Being more active during the day and engaging in regular exercise are very effective ways of improving heart health, managing your weight and keeping your muscles, bones and joints in good shape. It’s important to make a distinction between daily activity and regular exercise as there is a considerable difference.

What’s the difference between daily activity and regular exercise?

In very simple terms daily activity keeps the heart, lungs and muscles in relatively good order and can help regulate total body weight and blood glucose levels. Regular exercise can improve or condition the body to bring about physical changes such as improved heart and lung function, increased muscular strength, improved co-ordination and balance.

Taking a combined approach by increasing your day to day activity levels, increasing daily energy expenditure and including some regular cardiovascular and resistance exercise is likely to have the greatest impact on your overall health and wellbeing.

The NHS guidelines outline how much physical activity adults between the age of 19 and 64 should try to achieve each week to remain healthy. These apply equally to people living with HIV unless a member of your clinic team or GP has advised against making any changes to your daily activity levels due to a pre-existing health condition.

How can changes to my daily activity help me live well HIV?

Becoming more active and moving away from extended periods of low energy expenditure (sedentary behaviours) can provide an important protective factor for people living with HIV and help offset many of the co-morbidities listed earlier. Moving around more during the day and taking the opportunity to walk, cycle and climb stairs can significantly increase your daily energy expenditure. Increased daily activity provides the following benefits:

• Reduced your risk of cardiovascular disease, heart attack or stroke
• Help you manage blood pressure and cholesterol and triglyceride levels
• Help you maintain a healthy weight and protect against the development of weight gain attributed to body fat
• Protect against the development of type 2 diabetes and help you better manage existing type 2 diabetes
• Improve your strength, joint stability, balance and increase lean body tissue (muscle mass)
• Help preserve your bone strength and, in some cases, reverse bone mineral density decline.
• Improve your mood, concentration, help reduce day to day stresses and improve your sleep

Some ideas for increasing your daily activity levels:

• Think about the regular journeys you make and try to incorporate more walking time. This can include reducing the use of transport to get you to and from work, the shops or other daily journeys you make, or taking a lunchtime walk
• If you’re not particularly active at the moment set yourself realistic goals and gradually work these into your daily routine. Once you’ve established your new routine start to increase the time you spend each day being more active
• You don’t have to do all your chosen activity in one single block of time. If you have a sedentary job as an example, moving around for 2 to 3 minutes every hour can be very beneficial as it gets the heart and lungs working a little harder and importantly gets the blood circulating
• Using the stairs is a great weight bearing activity. This not only increases heart and breathing rate, it puts stress on your muscles, ligaments and bones which is essential for keeping things in good shape
• Adding resistance (heavy shopping bags as an example) when walking is a simple yet effective method to increase the demand placed on the heart, lungs and muscles, thereby increasing energy expenditure and activity intensity
• Walking briskly for at least 10 minutes each day is hugely beneficial. This will start to help condition the heart, lungs and cardiovascular system to become more efficient and help improve their function
• Think about how you can adapt activities such as housework and gardening to get the heart and lungs working harder or work your legs and arms harder. The important thing here is to make these activities a regular feature of your daily routine

Your regular exercise

Exercise can be defined as an activity which develops and maintains physical fitness and wellbeing. In very general terms these can be grouped into three distinct forms of exercise; aerobic, strength and flexibility.

Aerobic exercise is any physical activity where large muscle groups are used to create movement (brisk walking, running, cycling, swimming) and there is an increased demand for oxygen over and above the resting state of the body. The goal of aerobic exercise is to develop and maintain the heart, lungs and wider cardiovascular system to increase the delivery of oxygen to the working muscles, which prevents them from tiring. This is sometimes referred to as cardiovascular endurance. Activities that increase breathing and heart rate are capable of improving aerobic fitness levels when carried out over an extended period of time.

Exercise which improves strength (sometimes called resistance exercise) focuses on the development of the muscle cells (fibres) to bring about physical changes such as increased tone, size and strength. Muscle fibres require short bursts of energy which is developed by the muscle cells without the use of oxygen (anaerobically). Regular strength training can improve the efficiency of the anaerobic energy system, which in turn improves work rate.

Flexibility exercise can improve the range of movement around a particular joint and is important to prevent muscular imbalance which can cause joint problems and muscular pain. Flexibility exercises stretch the muscle fibres to lengthen them after a period of being in a contracted (shortened) state. Flexibility exercises improve recovery rates and reduce the possibility of injury.

Exercise can also include training that focuses on, accuracy, agility, power and speed. Here we focus on the benefits of aerobic and strength exercise in the context of living with HIV. Aerobic exercise can provide the following benefits:

• Increased heart and lung capacity which improves overall efficiency of transporting oxygen to your vital organs and muscles
• Increased efficiency and pumping volume of the heart (stroke volume) which over time reduces your resting heart rate and blood pressure
• Stimulates the growth of blood capillaries (vascularisation) which improves blood flow and oxygen supply to all parts of the body thereby improving circulation
• Increased aerobic capacity, which improves the capacity of your muscles to work for longer and at a higher intensity without tiring quickly
• Increased efficiency where carbohydrate and fat can be used as a source of energy for day to day activities, thereby improving your blood sugar and insulin regulation as well as reducing your cholesterol and triglyceride levels

Resistance training can have the following benefits:

• Stimulates muscle growth thereby improving muscle tone, size and strength
• Increases metabolic rate due to an increase in muscle tissue throughout the body, which increases the number of calories the body burns each day (metabolic rate)
• Develops the co-ordination and recruitment of muscle fibres, which improves muscle function, and your ability to lift heavier items more effectively
• Develops the co-ordination of muscle groups (quadriceps in the thigh as an example) to work together efficiently
• Helps strengthen ligaments and other connective tissue, which improves joint stability and helps prevent injury
• Improves efficiency of energy production within muscles fibres, which can help prevent your muscles becoming fatigued or tiring quickly

A combined approach of cardiovascular and resistance training is recommended for improving general fitness levels. Gradual warm up is an important part of any fitness plan, as is a cool down and the inclusion of flexibility exercises, which are sometimes overlooked. Here are some ideas to consider in relation to regular exercise:

• If you haven’t taken any regular exercise for a period of time, we suggest you discuss this with your GP before embarking on a new activity or exercise programme. This is particularly important if you have any health conditions or previous injuries that have prevented you exercising in the past
• Finding one or more activities you enjoy will help you get into the habit of exercising on a regular basis and help you stay motivated
• Activities such as outdoor running, brisk walking, cycling are all great ways of improving cardiovascular fitness. The important thing is to start off slowly and build up your endurance levels over time
• Activities such as Park Run, NHS Couch to 5K challenge are great ways of getting your family and friends involved, and will provide some additional support and motivation
• If you’re more a team sport enthusiast there are many sports to choose from which will help improve your cardiovascular fitness together with agility, balance and stamina levels
• If you’re considering joining a gym and you’re not familiar with the equipment, ask for a gym induction so you can safely use all the equipment. Some gyms will also offer to put together an exercise program for you
• If motivation is something you struggle with group exercise classes are a great way to stay motivated. Maybe join local groups who organise and run Zumba, Pilates or yoga class as examples. This is a great way to get fit and enjoy the social element of joining a local group
• There are many strength exercises that you can do at home, or as part of a park training group. Using body weight, dumbells and resistance bands can provide a very effective workout at home or in the park
• At the gym it can be beneficial to use fixed position resistance equipment when embarking on a new resistance training program. This form of resistance training helps build confidence, reduces the possibility of injury and improves muscle fibre recruitment and co-ordination
• Using barbells, dumbells, kettle bells and other equipment is a great way to develop muscular strength, muscle fibre recruitment and co-ordination of motor skills. Good exercise technique is essential to get the best out of the exercise and avoid injury
• Mixing up your training program can help avoid boredom and stimulate continual improvements in your fitness goals. You can make your workout more intense by reducing rest time, adapting exercises and increasing workload. There is no need to spend hours each time you exercise

Your smoking and tobacco use

Smoking is the number one risk factor when it comes to reduced life expectancy amongst people living with HIV. Smoking is strongly associated with higher risk of developing cardiovascular, heart and lung disease together with some cancers. Some studies have shown the risk of people living with HIV developing cardiovascular disease can be up to 3 times higher in those who smoke when compared those who don’t. Smoking cessation is an important consideration when thinking about living well with HIV into older age.

Smoking cessation

Smoking cessation programmes have become very well established in different healthcare settings, notably within GP and community pharmacy services. Specific support for people living with HIV who wish to give up smoking is somewhat fragmented, although some local HIV support charities may offer smoking cessation programmes. Here are some ideas to consider in relation to giving up smoking:

• Make a plan that’s realistic and set a date when you’ll go smoke free. Let your family members, friends and colleagues know when you’ll be quitting. You can set up a free online personal smoke free plan by using the NHS Smokefree online tool
• Identify which nicotine replacements you wish to use or have used in the past and get organised, so you have everything you need for your chosen date to stop
• If you intend to use a prescription treatment discuss this with your GP and get the prescribed treatment in advance of your planned stop smoking date
• Remember to check for any drug interactions with HIV medications which may reduce the effectiveness of some medications used to help with smoking cessation
• Quitting with a family member, friend or work colleague is a great motivational tool. Getting additional support from someone you know can be very helpful as you can see each other through the tough times and celebrate the milestones you set yourself
• Find out where you can get additional support. GP’s and community pharmacies often provide smoking cessation support by trained members of staff. You can find local services by visiting the NHS Smokefree Website, which also has a range of online support information
• Remind yourself why you want to stop smoking before the date you’ve chosen to go smoke free. Sometimes making a note of your reasons can be very helpful so you can revisit this when things get a little tough
• Put aside the money you would normally spend on cigarettes so you can treat yourself either at specific milestones or when you feel confident you’ve become smoke free. You can calculate how much you intend to save over a particular period. This can be a huge motivational tool to keep you on track
• It is said that the craving for a cigarette lasts between 5 and 10 minutes, after which the intensity will subside. Identify when you crave cigarettes and try to distract yourself during this period
• Giving up smoking can be extremely stressful, and many people reach for a cigarette when they feel stressed or anxious. Becoming more active, exercising, and other relaxation methods can help in the longer term to help reduce stress levels
• Think about the end goal when things get tough and revisit the reasons why you decided to give up smoking in the first place. Talk to family members, friends or work colleagues so they understand the best way to support you through difficult periods

Your drinking and alcohol use

Many people enjoy alcohol to help them relax and socialise with family or friends. Some experts believe there are no safe levels of alcohol use and in the longer term any use of alcohol can result in poorer health outcomes on a population level.

People living with HIV aren’t thought to be more at risk of developing alcohol related health conditions when compared to their HIV negative peer groups. There is very little evidence to demonstrate a particular interplay between alcohol, HIV itself or treatment. There are some indirect associations which are important to consider:

• Many of the drugs used to treat HIV are processed through the liver and the same is true of alcohol, which can make the liver work harder. Whilst the liver is a very robust organ, drinking in moderation and not overloading it with the by-products of alcohol metabolism will help the liver remain healthy
• Some studies have demonstrated blood alcohol levels can be higher in people who are not taking HIV treatment and have detectable viral load. It’s thought continued HIV activity around the digestive tract increases alcohol absorption, thereby raising blood alcohol levels
• Dual infection with HIV and viral hepatitis (Hep B or C) can impair the ability of the liver to process and eliminate alcohol and its by-products, which can lead to faster progression of liver disease
• Alcohol use is associated with an increase in blood fats known as triglycerides. This can lead to a condition known as alcoholic fatty liver disease, which can damage the liver over time, and increase the risk of developing cardiovascular disease
• Heavy alcohol use is associated with the development of hepatitis and the development to liver fibrosis. These changes can progress to severe liver disease (cirrhosis) or liver cancer. HIV related inflammation may play an important role in the progression of liver disease
• Drinking too much alcohol can make it more difficult to remain adherent to your HIV medication, either because you forget to take it or because of vomiting, which may result in incomplete drug absorption

Understanding your alcohol intake

The recommended number of units of alcohol per week for both men and women is 14. This recommendation was updated in January 2016, but many people remain unaware of the change. In practical terms, this equates to the following in a 7-day period:

6 pints of medium strength beer or lager

7 standard (125) glasses of medium strength wine

14 single spirit shots

Regular alcohol use above these levels can increase the known health risks. Drinking moderate amounts of alcohol over several days without a break can be as harmful as binge drinking. Where you consistently have more than 14 units of alcohol a week you may wish to reduce your alcohol intake to improve your overall health and wellbeing.

There are times when your alcohol use may become harmful to your health or starts to have a negative impact on other areas of your life such as treatment adherence, self-care, work, finances or your relationships. Recognising this can be difficult. Taking steps to get specialist advice can be very beneficial to help you reduce your alcohol intake in a safe and supported way.

If you believe your use of alcohol is becoming problematic there are a variety of ways to get help and support. You can often self-refer to local services, or you may find it helpful to talk things through with your GP or HIV clinic team. Here are some ideas to consider in relation to reducing your alcohol intake:

• Track your alcohol intake over a period of a typical week by using a smartphone app, or making a written note of what you drink, where you drink, and with whom you drink. This will help provide a baseline of how many units of alcohol you consume each week
• Get a better understanding of how many units of alcohol are in the drinks you most frequently consume. It can be difficult to understand the number of units in a particular drink, which is where smartphone apps can be very helpful
• Try to identify where and when you tend to drink the most alcohol each week and identify ways you can reduce either the number of drinks or the type of drink you have. As an example, a large spirit drink contains less alcohol than a pint of beer or a standard glass of wine
• Set yourself a goal which is achievable over a particular period of time. Cutting down gradually is likely to be the most successful and sustainable way of reducing your alcohol intake for the longer term
• Set yourself a budget of how much money you wish to spend on alcohol, perhaps taking cash out with you and leaving your bank cards at home. Set aside the money you would normally spend on alcohol and reward yourself when you’ve reached your goal
• If you’re out with friends pace yourself and maybe alternate alcoholic drinks with soft drinks. This can be difficult where a group of friends buy rounds of drinks, maybe consider opting out explaining that you want to reduce your alcohol intake
• Involve or challenge family members and friends to join in so you can support each other particularly when out socialising
• Consider buying small quantities of alcohol to drink at home, such as mini bottles of wine, pre-mixed spirit drinks or individual bottles of beer. Whilst this can be more expensive this can be a helpful strategy to employ and could actually work out cheaper in the longer term
• Try to increase the number of days where you don’t drink alcohol each week and consider increasing this over time
• Be kind to yourself when you’ve had more drinks than you intended to on a particular occasion. Refer back to your alcohol reduction plan so you can get back on track

Your recreational substance use

Many people use recreational substances to help them relax, socialise with friends, feel more confident and enhance other activities including the pleasure they get from sex. The majority of people feel able to manage their substance use without causing significant harm to themselves or others.

Recreational substances include marijuana, cocaine, ketamine (k or special k), methamphetamine (crystal meth, tina) Mephedrone (m-cat, meow meow) to name a few. It’s important to understand the safety aspects of taking recreational drugs in relation to treatment for HIV.

Can I use recreational substances now I’m taking medication?

The important thing to consider about the use of recreational substances is the high potential for interactions to occur with many of the drugs frequently used to treat HIV. Maintaining good levels of treatment adherence can also be a problem when under the influence of recreational substances.

Most clinic teams will encourage you to be open and honest about any substances you use for recreational purposes. They will provide you with the necessary advice when it comes to potential drug interactions, and safer substance use. By engaging with your clinic team in an open way they can also signpost you to other support services which might be beneficial where you wish to better manage your recreational drug use.

Substance interactions with HIV treatment

It’s always best to check for any potential interactions using the online HIV drug interaction checker where you have recently started or changed your treatment for HIV. Some of the more important interactions occur with the following classes of HIV medications:

Boosting agents:

• Cobicistat and low dose ritonavir are used in many frequently prescribed treatment combinations, which include darunavir, atazanavir, Rezolsta, Evotaz, Symtuza, Stribild, Genvoya
• Both cobicistat and ritonavir inhibit drug clearance through the liver. There can be subtle yet important differences in the way they interact with other drugs/recreational substances. It’s important to check for interactions where you’ve recently moved from a ritonavir boosted combination to cobicistat
• Levels of ketamine, benzodiazepines, drugs used for erectile dysfunction (Viagra, Cialis) crystal meth, mephedrone and MDMA can increase when taken with the boosted combinations highlighted above
• It can be difficult to be precise about drug interactions with recreational substances due to the inconsistency of the active drug in street acquired substances. It’s important to take a more cautious approach when using recreational substances and HIV treatment combinations that contain a boosting agent
• The use of anabolic steroids can be particularly problematic when taken alongside combinations that contain a boosting agent as there can be additional concerns around cholesterol and liver function

NNRTI class of drugs

• Treatment combinations that contain rilpivirine, etravirine, efavirenz and nevirapine can speed up the metabolism and removal of some drugs/recreational substances. This may mean a lower desired effect which can become problematic where you mix different substances, take larger quantities or inject to achieve the desired effect
• Levels of cocaine, ketamine, acid (LSD) and drugs used for erectile dysfunction (Viagra, Cialis) can be reduced when taken with drugs from the NNRTI class, which include single pill options Eviplera, Odefsey, Juluca and Atripla or single pill generic equivalent containing emtricitabine/tenofovirDF/efavirenz
• There may be interactions with efavirenz, etravirine and the use of cannabis, which may increase levels of THC. There may be a similar effect on heroin use, which may increase levels of the active substance (morphine)

The interactions listed above are the most notable but there may be other adverse effects with the use of recreational substances and HIV medications. These cannot always be anticipated due to variation in the quality and strength of street purchased items. Here are some points to consider in relation to substance use and HIV:

• Consider discussing your recreational substance use with your clinic team to get their advice on any interactions with your HIV treatment
• If you’ve recently started or changed treatment check for any potential interactions by using the online HIV drug interaction checker, which is also available as a smartphone app
• Allow enough time between doses as there may be a delay in the effect you’re expecting due to the nature of some interactions with your HIV medication. This might be particularly important with the use of GBL or GHB as there can be unexpected interactions with this substance
• If you inject or snort drugs always use your own equipment and never share needles or other equipment as this can provide a transmission route for HIV and hepatitis C
• It can be difficult to keep track and remain adherent to your HIV medication having taken recreational substances. If you miss a dose take it as soon as you remember
• If you find yourself missing doses on a frequent basis, talk to your clinic team and ask them to check your viral load, which can become detectable again
• If you need to take your treatment with food, you may find you’re not in the mood to eat. Having a small snack is usually enough to take your meds with, maybe a protein bar or something similar

Occasionally there may be situations where dependency to some substances will require the input of specialist services. It can be dangerous to suddenly stop taking a particular substance where dependency has developed. If you believe you require additional support, it’s advisable to discuss this with your GP or clinic team in the first instance.

If you think your use of recreational substances is causing problems it’s important to seek additional help and support. Generic support services are usually available where you can self-refer. There are very few that are specifically developed for people living with HIV. For further information visit Friday/Monday online resource to find local and national services.