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Alcohol Use, Highly Active Antiretroviral Therapy

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Alcohol Use, Highly Active Antiretroviral Therapy 33.3_9.1.10.qxd:32(1).qxp 9/8/10 11:43 AM Page 229 SPECIAL SECTION: MODELING HIV AND ALCOHOL’S EFFECTS FOCUS ON THE LIVER: ALCOHOL USE, HIGHLY The increasing problem of liver disease in the HIV pop­ ACTIVE ANTIRETROVIRAL THERAPY, AND LIVER ulation can be attributed to a variety of factors, including coinfection with HCV or hepatitis B virus (HBV), alcohol DISEASE IN HIV­INFECTED PATIENTS abuse, and toxic effects of the HAART medications on the liver (i.e., HAART hepatotoxicity). For example, depending Shirish Barve, Ph.D.; Rama Kapoor, M.D.; Akshata on the specific combination of medications used, up to Moghe, M.B.B.S; Julio A. Ramirez, M.D.; John W. 30 percent of patients experience severe hepatotoxicity Eaton, Ph.D.; Leila Gobejishvili, Ph.D.; Swati Joshi­ after initiation of their HAART treatment, as indicated Barve, Ph.D.; and Craig J. McClain, M.D. by at least a fivefold elevation of liver enzyme levels in HIRISH ARVE H S B , P .D., is the director of Pilot Projects in the Since the introduction of highly active antiretroviral University of Louisville Alcohol Research Center; a professor of therapy (HAART) in the 1990s, liver disease is emerging medicine in the Division of Gastroenterology, Hepatology and as a major cause of morbidity and mortality among HIV­ Nutrition, Department of Medicine, University of Louisville infected patients. This is attributed to a variety of factors, Medical Center; and a joint professor in the Department of including HAART hepatotoxicity, coinfection with Pharmacology and Toxicology, University of Louisville, all in hepatitis B and C virus (HBV and HCV, respectively), and alcohol abuse. Several studies have examined the Louisville, Kentucky. effects of HAART and HCV/HBV coinfection on liver RAMA KAPOOR, M.D., is an assistant professor of medicine in toxicity. However, the impact of alcohol consumption as a the Division of Infectious Diseases, Department of Medicine, cofactor for hepatotoxicity in HIV patients is only University of Louisville Medical Center, Louisville, Kentucky. beginning to be understood. Similar to the general population, alcohol use is common in the HIV population AKSHATA MOGHE, M.B.B.S., is a trainee in the University of but is often overlooked by health care providers. Louisville Alcohol Research Center and a graduate student in Approximately 25 percent of recently diagnosed HIV the Department of Pharmacology and Toxicology, University of patients are alcohol dependent; moreover, alcohol Louisville, Louisville, Kentucky. dependence has been associated with HIV treatment failure. Alcohol/HAART interactions appear crucial for JULIO A. RAMIREZ, M.D., is a professor of medicine in the the development of liver disease in HIV patients. Recent Division of Infectious Diseases, Department of Medicine, research has shown that alcohol abuse is associated with University of Louisville Medical Center, and in the Louisville severe hepatotoxicity in patients on HAART. Importantly, Veterans Administration Medical Center, Louisville, Kentucky. alcoholic­ and HAART­induced liver disease share many potential mechanisms of injury, including altered JOHN W. EATON, PH.D., is a professor of medicine, University metabolism of certain signaling molecules (i.e., cytokines) of Louisville Medical Center, and a joint professor in the and dysfunction of some cell components (i.e., proteasomes Department of Pharmacology and Toxicology, University of and mitochondria). KEY WORDS: Alcohol consumption; alcohol Louisville, Louisville, Kentucky. abuse; alcohol dependence; human immunodeficiency virus; highly active antiretroviral therapy; liver disease; hepatitis B; LEILA GOBEJISHVILI, PH.D., is a member of the University of hepatitis C; hepatoxicity Louisville Alcohol Research Center and a research scientist in the Department of Medicine, University of Louisville Medical n the era of highly active antiretroviral therapy (HAART), Center, Louisville, Kentucky. people who are infected with human immunodeficiency virus (HIV) live longer and are less likely to die of acquired SWATI JOSHI­BARVE, PH.D., is a member of the University of I 1 Louisville Alcohol Research Center and an assistant professor of immundeficiency syndrome (AIDS)­defining illnesses. (For a brief description of HAART, see the textbox.) At the same medicine in the Division of Gastroenterology, Hepatology and time, however, liver disease is emerging as a major cause of Nutrition, Department of Medicine, University of Louisville morbidity among HIV­infected people (Weber et al. 2006) Medical Center, Louisville, Kentucky. and is now a leading cause of death in these patients. For example, among people concurrently infected with HIV and CRAIG J. MCCLAIN, M.D., is director of the University of hepatitis C virus (HCV), cirrhosis was the underlying cause Louisville Alcohol Research Center; a professor of medicine of death in nearly 50 percent of the patients (Bica et al. 2001). in the Division of Gastroenterology, Hepatology and Nutrition, In a more general HIV population, liver disease was the second Department of Medicine University of Louisville Medical most common non­HIV–related cause of death, trailing Center; a joint professor in the Department of Pharmacology only cancer (Novoa et al. 2008). and Toxicology, University of Louisville; and chief of gastroin­ testinal medicine at the Louisville Veterans Administration 1 For a definition of this and other technical terms used in this article, see the glossary, pp. 288–291. Medical Center, all in Louisville, Kentucky. Vol. 33, No. 3, 2010 229 33.3_9.1.10.qxd:32(1).qxp 9/8/10 11:43 AM Page 230 SPECIAL SECTION: MODELING HIV AND ALCOHOL’S EFFECTS the blood2 (Sulkowski et al. 2000). This HAART­related et al. 2000). A recent study also observed that the levels of hepatotoxicity can lead to adverse patient outcomes by HIV in the blood (i.e., HIV viremia) were associated with causing fulminant hepatic failure. More commonly, howev­ the rate of fibrosis progression in HIV/HCV­coinfected er, the patients will progress from HIV infection to AIDS patients. Furthermore, suppression of HIV levels slowed because they discontinue their HAART treatment to pre­ fibrosis progression (Brau et al. 2006). Interestingly, another vent further liver damage. This problem appears to be study of HIV/HBV­coinfected patients suggested an worsening because in a review of records of deceased HIV increased incidence of liver­related disease but no poorer HIV patients, the proportion of patients who discontinued outcomes (Konopnicki et al. 2005). HAART because of hepatotoxicity increased from 6 percent in 1996 to 31.8 percent in 1998–1999 (Núñez 2006). The Centers for Disease Control and Prevention (2008) Highly Active Antiretroviral Therapy estimated that at the end of 2006 approximately 1,106,400 HIV­infected adults and adolescents were living in the Treatment of HIV infection and AIDS is complicated by United States. This represents an increase of approximately the fact that the virus can rapidly adapt to the presence of 112,000 people (or 11 percent) from 2003. Similar to the antiretroviral drugs, resulting in resistance to those drugs. population at large, alcohol use is common in the HIV­ To prevent or delay resistance development, clinicians infected population. It has been estimated that approxi­ therefore are using a regimen consisting of a combination mately 25 percent of recently diagnosed HIV patients also of several types of antiretroviral drugs that target different were alcohol dependent; moreover, concurrent alcohol stages in the lifecycle of the virus. Such regimens are dependence has been associated with failure to respond called highly active antiretroviral therapy (HAART). to HAART (Miguez et al. 2003). Although alcohol con­ Drug types that are most commonly used in these combi­ sumption is known to contribute to liver damage, the nation regimens include the following: impact of varying levels of alcohol consumption in people with HIV is only beginning to be defined. Alcohol–HAART • Nucleoside/nucleotide reverse transcriptase inhibitors interactions are emerging as a critical factor in this patient (NRTIs), which inhibit the formation of viral DNA group because recent research has shown that alcohol by incorporating into the newly formed DNA abuse is associated with severe hepatotoxicity in patients molecules, thereby preventing further elongation of on HAART (Núñez 2006). Importantly, alcoholic liver those molecules; disease (ALD) and HAART­induced liver injury share many potential mechanisms of injury. • Nonnucleoside reverse transcriptase inhibitors This article explores the interactions of HIV infection, (NNRTIs), which bind to the enzyme that synthesizes HAART, and alcohol abuse in the development of liver the viral DNA (i.e., reverse transcriptase) and interfere disease in HIV­infected patients, both with and without with its activity; and coinfection with hepatitis viruses. It also describes some • Protease inhibitors (PIs), which disrupt the assembly of the potential mechanisms through which alcohol abuse of new virus particles by preventing the activity of an and HAART may cause liver damage. enzyme (i.e., protease) necessary for generating the necessary proteins from precursor molecules. Interaction of HIV, HCV/HBV, However, additional types of drugs have been devel­ and Alcohol oped or are under investigation to extend the treat­ ment options available to HIV­infected patients. A substantial portion of HIV­infected people also suffer Most HAART regimens consist of at least three drugs from
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