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When the band stops….

If you don’t normally read my Early Career columns you should know two things about me to understand the context of this piece:  1) I am a nurse and 2) My day job is as a researcher examining how to improve heart health in adults living with HIV.

The first time I heard of HIV was when my middle school health teacher played the movie “And the Band Played On”. If you haven’t seen the film or read the book, it’s the story of early years of the HIV crisis in America. Yes, it’s about the intersection on politics and health in the face of an unknown virus spreading among marginalized and vulnerable people. But it’s also about how scientists, health care professionals, advocates, and people from all walks of life come together to create a groundswell of tangible support and change for those infected with and affected by HIV.

I’ve been thinking a lot about this film these days in the midst of the COVID-19 pandemic. When every day I wake up wondering what the headlines will be and every song on the radio, speech, and swing of the stock market seems fraught with apocalyptic symbolism. There is a pervasive, and understandable, fear of the unknown, desire for control, and for some an insidious need to blame others for disease.  And then there is the grief. The grief not only for those who have and will succumb to this virus. But the widely felt grief that life will never be the same as it was before COVID-19 came into our consciousness.  It reminds me of how patients and caregivers have described the early years of the HIV epidemic.

But in the 40 years since the HIV epidemic what have we learned that can help us today? I’d also love to hear your thoughts on this but here those I’ve been thinking about.

  • Trust science. It’s a very human instinct to believe in quick cures and conspiracy theories but the only thing that will help us understand how to prevent, mitigate, and treat COVID-19 is science. Science is a careful, systematic, data-driven and rigorous process by which hypotheses are developed, tested, refined and re-tested until we have the answer. This is how we developed the first HIV tests and highly effective HIV medications, and it is also how we are slowly inching forward towards an HIV vaccine. This is how we are now developing a test for COVID-19, how we will develop treatments, and eventually how we will develop a vaccine. Do your best to ignore any advice, product, or theory you hear that is not grounded in the scientific method and widely shared by reputable scientists.
  • Be kind. People are going to say and do things you don’t agree with a lot over the next few months. People are going to be stressed out with new family, work, financial and social pressures. We are undoubtedly going to be asked to give more up than we have had to give in maybe a generation. Some of us are going to have to work more hours than we thought possible (at least since work hour restrictions were enacted). So, while it’s going to be hard, we need to take extra care to be kind to one another—to say kind things; restrict the sarcasm, judgment and unsolicited advice (in person and on social media); drive a little more calmly; and simply find ways to share kindness to your family, community, team, and neighbors at a responsible distance.
  • The band is more than the conductor. To get through this pandemic, we will need to draw on the skill sets of many. We need those skilled laborers who work to manufacture personal protective equipment, delivery teams who make sure the equipment gets where it needs to go, we need people to sanitize and stock grocery stores, we need musicians and artists to remind us to see the beauty in the world around us, and telecommunications staff to make sure the internet works. And in health care settings—the epicenter of the pandemic—we need food service workers, respiratory therapists, housekeeping staff, administrators, pharmacists, social workers, schedulers, faith leaders, nurses, advanced practice professionals, and physicians.  They are part of a health care machine that will keep us safe and ensure that many of us never see the worst of this disease. Few chose these jobs anticipating high salaries, professional autonomy, or glory, and many will not be publically acclaimed as heroes for their critical contribution during this time. But like all front line soldiers, they deserve our respect, honesty, protection and acknowledgment; and we must encourage those who are leading during this time to recognize this valuable work.

The title “And The Band Plays On” refers to a society that by and large ignored the early AIDS epidemic which led to increased transmission of HIV and countless deaths. Despite some similarly notable fumbles by political leaders, the COVID-19 epidemic is not the early HIV/AIDS epidemic. In the span of less than a week, hundreds of millions of people in the United States and around the globe have listened, learned, and stopped in an effort to decrease transmission and reduce deaths. We don’t yet know if these actions will work, and we may never fully understand their impact.  That we collectively acted (or in this case stopped acting) tells me that we will weather the next few months as long as we do so together.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

 

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Heart Health and HIV: An Opportunity for Global Health Partnership

Slightly over five years ago, I immersed myself in a growing literature that documented the increase in heart disease in people living with HIV (PLHIV). While almost of all of these studies were in well-developed “high income” countries, the conclusion was always the same. The HIV medications worked, and those who had access to them were aging and developing conditions associated with aging including, prominently, cardiovascular disease (CVD). People living with HIV seemed to be developing these conditions more frequently than those who were not living with HIV, and no one was able to tease apart the myriad reasons why this was happening.

 

Global Burden of Atherosclerotic Cardiovascular Disease in People Living With HIV                                          
DOI: (10.1161/CIRCULATIONAHA.117.033369

Others had the same realization and earlier this year. Anoop Shah, MD, from the University of Edinburgh, conducted the first meta-analysis examining the global burden of CVD in PLHIV. Pooling data from almost 800,000 PLHIV with 3.5 million person years of follow up, they found that the global burden of HIV-Associated CVD has tripled in the past 20 years, especially in low and middle-income nations.

Specifically, Dr. Shah and his team measured the population attributable fraction of CVD in PLHIV. This metric combines the risk associated with CVD with the prevalence of HIV- an approach that can quantify the actual impact of risk on a population. This is important because in low and middle-income countries where the HIV prevalence is high and resources are scarce, interventions to reduce the risk of CVD will likely have a bigger impact. Dr. Shah’s work revealed that those in sub-Saharan Africa experience a “double hit” of both HIV and CVD, with higher rates of traditional risk factors such as high blood pressure, and context-specific risk factors including air pollution.

To address these risk factors, Dr. Shah suggests that while there are studies leveraging cutting edge science to help us identify those living with or at risk for CVD (e.g. biomarkers), we need more research testing evidence-based strategies to improve cardiovascular outcomes in PLHIV in low and middle-income countries. This includes testing traditional pharmacological (e.g., antihypertensive and dyslipidemia) and non-pharmacological (e.g., diet, exercise and smoking cessation) strategies tailored to the setting and the population. Critically, this research must also account for the pivotal role health systems have in delivering these interventions.

This year the theme of World AIDS Day is “Building Partnerships through Leadership” and Dr. Shah captured this promise when discussing how to improve health systems to reduce CVD.  “Based on my experience, in Sub-Saharan Africa HIV clinics are incredibly well run and effective, but they only do one thing- treat HIV; but what if we could partner with this HIV clinics across Africa [and other low and middle income settings] to start to provide better CVD prevention and treatment? By building on the existing systems, and expanding to other populations, we could deliver the change that is needed to improve cardiovascular health to PLHIV and beyond”.

Today is World AIDS Day and I am part of the first generation where AIDS has always existed.  I was born a week after the MMRW report  documented the first case of what would become known as AIDS. Since then we have made so much progress, and continue to make strides in preventing, treating, and eventually curing HIV. I look forward to the day when HIV will no longer be a part of anyone’s life. But until that happens, my work, and the work of many scientists, clinicians, advocates and allies will continue to build a better understanding of how to help all PLHIV enjoy the healthiest life possible, with less risk for cardiovascular diseases and stroke.  By working with HIV organizations there are incredible opportunities for innovative and exciting partnerships to improve cardiovascular health in PLHIV, and millions of others around the globe. The American Heart Association can and should have an important role in this quest for longer, healthier lives.

Over the next year, I will explore what is known about the various causes of cardiovascular disease in this population in this series on Heart Health and HIV. I will work to incorporate high quality science with the perspectives of the both clinicians caring for PLHIV and the voices of the patients themselves. I look forward to engaging with all of you and, together, trying to solve these important issues.