Presentation from the AFAO National Symposium on Prevention, held in Sydney, Thursday 27 May, 2010.

1. It would be very sad to survive HIV and die of something else that was preventable. Epidemiologist Dr. John T. Brooks referring to obesity Centersfor Disease Control and Prevention, in Alicia Chang, "Obesity a Problem in HIV Population", Associated Press, 4 October 2007.

3. smoking

6. lipodystrophyBut as HIV has become a ‘chronic disease’, long-term complications related to diet, overweight, and obesityneed greater attention

7. US Based Findings on HIV & Obesity 2001 High prevalence of obesity amongHIV+ patients: 34% overweight & 9% obese (Hodgson) 2005 58% of HIV+ women and 42% of men either obese or overweight: 31% women and 30% of men obese (Amorosa) obesity more common than wasting amongst HIV-positive people 2006 13% of HIV+ men and 29% women were obese (Hendricks) the prevalence of overweight & obese had increased had over preceding 8 years 2007 63% of HIV+ patients at two hospitals were overweight or obese, including some 30% of people with AIDS (Crum - C) many are prone to the same bad habits as many HIV negative Americans: poor eating choices and lack of exercise

8. US supposition Elevated weight: to serve as a protective cushion against future wasting to mask HIV from friends or acquaintances

9. Australia Lack of data HIV Futures 6 ... when asked about health management strategies, almost all participants agreed that exercise, healthy eating and an optimistic outlook were important or very important strategies. Notably, those who indicated they exercised and ate well were more likely to agree with the respective statements than those who did not.

10. HIV - Implications of Weight Loss? ... as weight loss is a documentedpredictor of decreased survival of PLHIV, the role of intentional weightloss in overweight and obese HIV infected people also requiresthorough scientific study.

11. LGBT & Obesity Gay men enjoy some statistical privilege Private Lives, 2004: Gay men less likely to be overweight or obese than the Australian average male: 43% to 54% (Pitts) Little research into overweight and obesity among gay men Limited effort to develop means to reach gay men who are overweight

12. Smoking and HIV HIV Futures 5 - almost half of PLHIV smoke (48%), more than twice the rate of the general Australian population (23%)

13. Interrelationship – Smoking & HIV HIV+ More likely to develop throat, lung, anal & colon cancers Emphysema likely to occur earlier Smoking: Increases risk of cardiovascular disease, exacerbating the effect of HIV infection and problematising treatments Increases risk of oral health conditions, including Oral Hairy Leukoplakia (Epstein Barr Virus), Oral Candidiasis (Thrush), Mouth Ulcers, and Oral Cancers Compounds issues around diabetes (becoming more common as side effect of ART). Directly affects insulin sensitivity and negatively affects blood sugar metabolism. May also compound the negative impact of HIV infection and treatment on bone mineral density, triggering osteoporosis and osteopenia .

14. Smoking Cessation US study found smoking cessation in symptomatic HIV positive people can significantly improve symptom burden for HIV positive people from as early as three months of cessation. Virrine 2007

15. Broad Implications for Targeted QUIT Initiatives Decisions to quit smoking are not made solely by isolated persons, but rather they reflect choices made by groups of people connected to each other both directly and indirectly at up to three degrees of separation. … Indeed, cessation programs for smoking and for alcohol use that provide peer support — that is, that modify the person’s social network — are more successful than those that do not. Christakis and Fowler, ‘The Collective Dynamics of Smoking in a Large Social Network’, The New England Journal of Medicine, 22 May 2008,

16. Alcohol Consumption and HIV Alcohol consumption impacts HIV in terms of risk practices, access to treatments and disease progression.

17. Alcohol & Risk Behaviours Some studies have sought to establish an association between alcohol, drug use and unsafe sex, however, a causal link remains disputed. Newman - barriers and incentives to HIV treatment uptake among Aboriginal people in WA found alcohol ‘featured in the accounts of many participants, as a key element of the risk context in which they acquired HIV’. Tawk - alcohol consumption identified as factor associated with inconsistent condom use among multi-partnered HIV-negative men.

18. Alcohol & Risk Behaviours Korner, Hendry and Kippax, 2005 Understanding of ‘risk’, documenting physical, social and emotional contexts in which unsafe sex occurs. Contexts interact in various ways, and alcohol is just one factor at play . Many participants reported ‘being in control despite being seriously affected by alcohol. Some emphasised that using condoms was a matter of routine, irrespective of drugs and alcohol with the exception of this particular episode. Where unprotected sex occurred in conjunction with drugs and alcohol, drugs and alcohol were not seen as an excuse. Rather, some participants emphasised own role in allowing unsafe sex to happen and insisted that they should have been in control.

19. Access and Adherence to HIV Treatments Newman, 2007 alcohol consumption one of the main barriers to treatment - 11 of 20 Aboriginal participants on ART. alcohol featured … as a perceived factor in the progression of infection. Some had stopped drinking, but those who continued reported difficulties in maintaining treatment regimens. If you've had a hard night out it stops you. But you know, you make it up until … You don't double your dose but you take your one dose again … until you start catching up. Participants expressed a willingness to comply with treatment regimens but adherence was compromised by heavy regular alcohol consumption.

20. Alcohol & Disease Progression Acute and chronic alcohol abuse impairs various functions of the immune system and has been implicated as a cofactor in HIV disease progression. Samet, 1996 Heavy drinkers on ART were more likely to have higher HIV viral load (after adjustment for medication adherence). In those not on ART heavy drinking was associated with lower CD4 cell counts. Futures 5 77% of respondents had consumed alcohol during the previous 12 months, suggesting a lower percentage of Australian PLHIV consume alcohol than in the general population (some 83%). approximately one in five (19%) respondents felt they drank more alcohol than they would like.

21. Fit with the National HIV Strategy? Communicate specific expertise of the HIV community sector in developing and delivering targeted programs to HIV-affected communities, especially gay communities ... as model Work out how the HIV response, and particularly the National HIV Strategy, might ‘fit’ with or link to wider preventative health strategies Ensure issues are not siloed, duplicated or overlooked Minimise frustration constantly reiterating the same policy arguments in different, unlinked forums

22. Targeting HIV and LGBT Populations Impact HIV and LGBT omission as the preventative health framework is rolled out, and strategies are designed in detail.

24. How can we impact those with values outside ‘mainstream, eg, gay men who have railed against dominant messages about ‘perfect’ bodies?

25. How do definitions of ‘health’ correlate to a sense of ‘wellbeing’?

26. How do descriptions of HIV as a ‘chronic disease’ fit within this new preventative health framework?