HIV Weekly - 25th January 2012

Support provided by HIV doctors during routine clinic visits can help their patients stop smoking, according to new Swiss research.

Rates of lung cancer and cardiovascular disease are higher in people with HIV compared to the general population.

Smoking is the biggest modifiable risk factor for such illnesses.

Many people who smoke want to quit. However, it can be hard, and most people need some help - either professional support or, in some cases, the use of medication.

Therefore, between 2007 and 2009, all doctors from an HIV clinic in Zurich received specialist training to equip them with skills to support patients who wanted to stop smoking.

Compared to patients at other HIV clinics in Switzerland, those who received their care in Zurich were more likely to stop smoking. They were also less likely to restart after they had quit.

After taking into account other factors, researchers found that patients in Zurich were 25% more likely to stop smoking. They were also 25% less likely to restart.

The research identified some patients who found it harder to quit. These included people who injected drugs, heavy drinkers and people with depression or other mental health problems.

The Swiss doctors believe that support to stop smoking should be provided in all consultations between HIV-positive people and their doctors.

Want to stop smoking? Talk to your doctor, someone else at your HIV clinic, your GP, or another professional involved in your care. There is lots of support available – local health services will usually provide group support and sometimes local HIV and LGBT organisations offer workshops as well. Try http://smokefree.nhs.uk for more information.

Research conducted in the US and Spain shows that more needs to be done to ensure that people at risk of hepatitis A or B are vaccinated against these infections.

UK HIV treatment guidelines recommend that all people with HIV should be vaccinated against hepatitis A and hepatitis B.

Hepatitis A can cause a short, unpleasant illness that can be more severe in people with other risk factors for liver disease.

Hepatitis B can turn into a long-term illness that causes serious health problems.

People with HIV have an increased risk of these infections, largely because they can be transmitted in the same way as HIV is - through unprotected sex or, in the case of hepatitis B, through injecting drug use.

Vaccinations are available against both infections. They can work well in people with HIV. However, booster doses may be needed. Therefore antibody levels should be monitored regularly as part of routine HIV care.

Researchers in the US found that 56% of people with sexual or drug use risk factors for hepatitis B had not been vaccinated against the infection.

Separate research conducted in Barcelona found that city-wide vaccination programmes were not preventing periodic outbreaks of hepatitis A among gay men. Approximately a quarter of people diagnosed with the infection were HIV positive. However, more targeted programmes, such as one offering vaccinations to users of gay saunas, were successful in reducing new hepatitis A infections.

In the UK, free hepatitis A and B vaccinations are available from HIV clinics, sexual health clinics, and GPs.

Advice about the management of common side-effects caused by hepatitis C protease inhibitors has been published.

Telaprevir (Incivek / Incivo) and boceprevir (Victrelis) were recently approved for the treatment of hepatitis C genotype-1 for people with monoinfection (i.e. only hepatitis C). These protease inhibitors are licensed for use in combination with pegylated interferon and ribavirin.

Clinical trials are currently underway to see how safe and effective these new drugs are in people who also have HIV (co-infection). However, some coinfected people have already started taking them.

Studies conducted in monoinfected patients showed that telaprevir and boceprevir could cause side-effects.

These include anaemia, rash and itchy skin, as well as nausea, diarrhoea and anorectal symptoms.

The recent article looked at how common these side-effects were and how they could be managed.

Approximately 50% of people treated with boceprevir developed anaemia, as did 40% of those taking telaprevir. It is thought this is because both drugs have a suppressive effect on bone marrow.

It is already known that anaemia can be a side-effect of ribavirin. The addition of either protease inhibitor appears to make this worse.

Erythropoietin (EPO) increases red blood cell count and it was widely used as a suportive therapy in the boceprevir studies, but this may not be a viable option in routine care.

Anaemia was managed in approximately a quarter of patients by reducing the dose of ribavirin. This did not appear to reduce the likelihood of treatment working.

In the boceprevir studies, only a ribavirin dose reduction of 60% or more of the planned initial dose affected virologic outcomes. Reducing the ribavirin dose when hepatitis C viral load was undetectable appeared to be the safest option.

However, use of EPO meant that full-dose ribavirin could often be maintained, the supportive therapy leading to an improvement in patient quality of life.

Skin complaints were also a common side-effect of the two drugs.

Most involved rash or itch and this was generally mild to moderate. However, a serious rash developed in 6% of people taking telaprevir and there were a few cases of severe cutaneous (skin) reaction. All severe reactions resolved when telaprevir therapy was stopped.

It’s important that doctors are able to distinguish between manageable skin conditions, severe rash and a severe cutaneous adverse reaction.

Localised rash, or a widespread rash covering less than 50% of the body surface area, should be manageable, but requires close monitoring for signs of progression. If the rash continues to progress, telaprevir should be stopped. If the rash does not improve within seven days, ribavirin should also be stopped.

In cases of severe rash covering at least half the body surface, or where the rash is accompanied by systemic symptoms such as fever, or where ulceration, skin peeling or other lesions are present, a specialist skin doctor (dermatologist) should be consulted. Telaprevir should be stopped and, if there is no improvement within seven days, ribavirin and/or pegylated interferon should also be stopped.

In the most severe cases, where systemic symptoms are present together with eosinophilia (an abnormality in white blood cell count), or where Stevens Johnson syndrome has developed, all drugs should stopped immediately and the patient should be hospitalised.

Less serious rash can be managed by:

• Emollient creams
• Topical corticosteroids
• Antihistamines (not astemizole or terfenadine)
• Baking soda (half a cup) or oatmeal in bath water
• Wearing loose-fitting clothes.

Telaprevir was also associated with some anorectal symptoms. These tended to develop during the first two weeks of treatment and involved haemorrhoids (piles), anal itching, discomfort and rectal burning. The symptoms were generally mild. However, a few people stopped taking telaprevir because of them.

It’s recommended that people who have these symptoms should have a rectal examination to rule out other possible causes.

Both protease inhibitors are processed by the body using the liver. This means that they can interact with other drugs and care is needed when some other common types of medicine are used. These include some anticonvulsants, the herbal antidepressant St John’s wort, erectile dysfunction drugs, and some medicines used to treat heart complaints.