HIV Weekly - May 2nd 2006

  • HIV prevention: A legal bid has been launched to force the UK government to provide more information about, and access to, post-exposure prophylaxis (PEP) for HIV. An aidsmap.com news feature takes a detailed look at PEP.
  • Recreational drug use: Few gay men in the UK use the recreational drug methamphetamine, a large study has found. However, higher levels of use were found amongst HIV-positive gay men, particularly those with larger numbers of sexual partners.
  • Anti-HIV treatment: A new study has further underlined the importance of proper adherence to HIV treatment, this time finding that it’s not just the number of doses that matters, but also the interval between doses. Use of the protease inhibitor Kaletra has been linked to an increase in blood pressure, but this was partly because of an increase in weight. And new formulation of Kaletra moves closer to approval in Europe.
  • HIV and hepatitis C: People with HIV who also have hepatitis C do less well after starting anti-HIV treatment, possibly because they spend less time actually taking treatment than people who only have HIV.

HIV Prevention

Most people with HIV in the UK were infected with the virus as a consequence of unprotected sex. Using condoms correctly is an excellent way of avoiding passing on HIV and most other sexually transmitted infections. Other ways people reduce their risk of infecting somebody else with HIV is to have sex only with other HIV-positive people (sometimes called serosorting); to limit their number of sexual partners; or to avoid having sex altogether – something which most people would find very difficult or impossible.

Anti-HIV drugs can also be used to try and prevent infection with HIV if a person is exposed to HIV during sex. This is called post-exposure prophylaxis, or usually just PEP for short. UK guidelines recommend that PEP should be provided if there is a significant risk of HIV transmission occurring – for example after unprotected sex anal or vaginal sex or a condom “accident” where one of the partners is known to be HIV-positive.

A gay man is bringing a case against the UK government because he wants what he sees as barriers to the current provision of PRP removed. The issues involved in this case are examined in an aidsmap.com news feature.

It is important to remember that PEP is not 100% effective, and it isn’t a kind of “morning after pill.” To be effective, PEP should be provided within at most 72 hours of the possible HIV exposure occurring, but many doctors think that this is far too late, and think that for it to work in the best possible way it needs to be provided much sooner – possibly no more than four hours later.

If you think that one of your sexual partners may need PEP, then contact your local sexual health clinic or HIV clinic immediately. If these are closed, then go to the accident or emergency department or see if your hospital had an on-call HIV doctor.

Anti-HIV treatment consisting of three (occasionally, two) drugs is taken for a month as part as PEP. Although the drugs used for PEP can cause side-effects, they are considered to be safe. Avoid the temptation to give any anti-HIV drugs that you may be taking to your sexual partner for PEP. It might not be safe to do this, particularly if you are taking abacavir (Ziagen) or nevirapine (Viramune) as these drugs can cause a potentially fatal allergic reaction or severe side-effects.

Recreational drug use

The recreational drug methamphetamine (also known as crystal meth or Tina) has been linked to risky sex and an increased risk of becoming infected with HIV, as well as faster HIV disease progression in studies in the US.

A study conducted in 2004 in gyms in central London seemed to show high levels of methamphetamine use amongst gay men in the UK’s capital. This study, which involved 750 men, showed that 20% had used methamphetamine in the previous year.

This statistic was recently used in a television programme broadcast on BBC3 called, The Trouble with Gay Men . This programme characterised gay men in the UK as ignoring the risks posed by unprotected sex and recreational drug use.

However, new information published this week shows that the actual level of methamphetamine use amongst gay men in the UK is much lower than the figure indicated by the gyms study. The 2005 Gay Men’s Sex Survey conducted by the UK’s largest charity the Terrence Higgins Trust and Sigma Research was completed by over 15,000 gay men and found that 3% of these men had used methamphetamine in the previous year and that less than half of one per cent – fewer than 50 men completing the survey – were regular users of the drug.

But the survey did find higher levels of methamphetamine use in London, where 7% of gay men reported use of the drug in the previous twelve months. An even higher level of usage was found amongst the 520 HIV-positive gay men who completed the survey in London, with 150 (20%) saying they had taken methamphetamine. The highest usage of all was seen in HIV-positive gay men in London who had a lot of sexual partners (30 or more a year). Of these 158 men, 55 (35%) said they had used methamphetamine.

The use of methamphetamine, like any recreational drug can have a negative impact on your health. There has been a lot of research looking at methamphetamine use by people with HIV – it’s important to know that these studies have consistently found that methamphetamine means worse health and not doing as well on HIV treatment. Here are a selection of studies reported on aidsmap in recent years:

Anti-HIV treatment

Adherence

For anti-HIV treatment to work effectively, it is essential to take it properly. You should aim to take all your doses every day, at the right time and in the right way, making sure you observe any food requirements.

The technical word used to describe taking HIV treatment properly is adherence.

Anti-HIV drugs need to be taken very rigorously, and doctors know that at least 95% of all doses need to be taken. This means missing no more than a dose a month if you are taking once-daily treatment, or a couple of doses a month if you are taking twice-daily treatment.

If you don’t take your HIV treatment correctly there’s a chance that HIV will become resistant to the anti-HIV drugs you are taking, and possibly similar drugs as well meaning that you have fewer drugs available to treat your HIV. In addition, the amount of HIV in your body, your viral load will increase, your immune system, measured by the number of CD4 cells, will fall, and your risk of becoming ill because of HIV will increase.

A new study has shown the importance of not only taking the doses of your anti-HIV drugs, but making sure that you take them at the same time every day. It found that people who took their treatment at the same time every day had lower viral loads than people who did not. The study involved 129 people with HIV and lasted for a year.

Side-effects – blood pressure

Anti-HIV treatment means a longer, healthier life, and in countries like the UK the amount of illness and death caused by HIV has fallen dramatically since effective HIV therapy became available in the late 1990s. Much of the serious HIV-related illness that is now seen often occurs in people who were diagnosed with HIV after having been infected for a long time and had very weak immune systems as a result.

Like all medicines, anti-HIV drugs can have unwanted side-effects. Some of these are most noticeable in the few weeks or months of treatment before lessening or going away completely, and they can often be controlled with simple treatments such as headache pills, anti-sickness pills, or treatment to control diarrhoea.

However, it is known that some anti-HIV drugs can cause longer-term side-effects. In particular, there is concern that HIV therapy can cause a syndrome called lipodystrophy that can involve changes in body fat shape and increased levels of fat in the blood. The changes in body fat shape, including facial wasting, can be very distressing and stigmatising. Increased levels of fat in the blood can have serious long-term health consequences, including an increased risk of heart disease and diabetes.

A new American study has found that people taking the protease inhibitor Kaletra (lopinavir/ritonavir) have a risk of developing high blood pressure. It is well known that high blood pressure can cause heart disease and stroke.

The study involved 444 people who were starting anti-HIV treatment for the first time. Doctors wanted to see if there were any factors associated with an increase in blood pressure, which was measured every month.

About a quarter of people experienced an increase in their blood pressure. These people were more likely to be aged over 40.

It was also found that certain anti-HIV drugs were linked to an increase in blood pressure. These included the protease inhibitor Kaletra and also tenofovir (Viread) with 3TC (lamivudine, Epivir).  But there was also another important finding: increased blood pressure seemed to be linked to an increase in weight after HIV treatment was started and that this was likely to partly explain the increase in blood pressure seen by the researchers.

If you have been taking anti-HIV treatment, then your blood pressure should be regularly measured at your HIV clinic. Talk to your doctor or another member of your healthcare team if you are worried about your blood pressure. There is a lot you can do to help control your blood pressure, including stopping smoking, taking regular exercise, and eating a healthy diet.

New Kaletra formulation

A new tablet formulation of the protease inhibitor Kaletra  (lopinavir/ritonavir) has cleared a key hurdle on its way to receiving full approval in Europe. The scientific committee of the European Medicines Agency (EMEA) provided a positive opinion on the drug, which should receive marketing approval in the next few months.

The new tablet formulation, which has already been approved in the USA, will mean that people will only have to take two pills twice a day instead of the current twice-daily dose of three pills. Another major advantage of the reformulation is that it does not require refrigeration.

HIV and hepatitis C

Liver disease caused by hepatitis B or hepatitis C virus is now one of the leading causes of illness and death amongst people with HIV in countries like the UK where anti-HIV treatment is available. Although treatment for hepatitis C is available, it is less effective in people with HIV than it is in people who only have hepatitis C.

There are also concerns that people with HIV who also have hepatitis C may do less well on anti-HIV treatment.

A new study involving every patient in Denmark who has HIV and hepatitis C and who started anti-HIV treatment has found that people with HIV/hepatitis C have a poorer outcome after starting HIV treatment than people who only have HIV.

Although people with HIV/hepatitis C had similar CD4 cell counts and viral loads to people who only had HIV, doctors found that those with both infections were much less likely to experience a fall in their viral load below 500. They think that this could be because people with HIV/hepatitis C took less HIV treatment, being more likely to take a treatment interruption lasting for three months or more. In addition, people with both infections had a lower average increase in their CD4 cell count compared to those with only HIV.

What’s more, more people with hepatitis C died. Deaths because of liver disease accounted for some of these additional deaths, but the Danish doctors also noted that people with HIV/hepatitis C were also more likely to die of HIV-related causes than people who only had HIV.

Higher rates of injecting drug use amongst people with HIV/hepatitis C and poorer adherence to HIV treatment are put forward by the Danish researchers as possible reasons why coinfected people did less well.

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