HIV update - 16th April 2014

Hepatitis C treatment

2014 continues to be a year of extraordinary advances in the treatment of hepatitis C. Four weeks ago, HIV Update summarised studies of several new drugs for hepatitis C presented at a conference in Boston. Since then, another conference – this time in London – has heard encouraging news of even more new drugs and further research into the drugs that were discussed in Boston. In many trials between 95 and 100% of people have been cured of hepatitis C.

In London, new treatment guidelines for hepatitis C were presented.

Until recently, it was thought that recommendations for treating people who have HIV and hepatitis C co-infection had to be different from recommendations for people with hepatitis C mono-infection. This was because people with HIV co-infection tended to have a poorer response to hepatitis C treatment and separate clinical trials were needed.

But it now appears that when a potent combination of two or three hepatitis C drugs (including new drugs) is taken, people with HIV co-infection can have results that are comparable to people who only have hepatitis C.

For example, a study in co-infected people with genotype 1 HCV infection showed a 100% cure rate after twelve weeks of treatment with the combination of sofosbuvir and ledipasvir. This combination is likely to receive European approval in January 2015.

The new guidelines therefore recommend an identical approach for both co-infected and mono-infected people. This means that the new drugs can be made available to people with HIV more quickly, although doctors must be alert to the possibility of drug-drug interactions with HIV medication.

The guidelines recommend that, as much as possible, the newest direct-acting antiviral drugs should be used, even before they have been approved by regulators.

Although some pharmaceutical companies plan to package their firms’ drugs together into a single pill, the guidelines say that the best approach for patients who will be treated in 2014 is to ‘mix and match’ the best drugs from different pharmaceutical companies before any of these combination pills become available.

In the guidelines, different advice is given according to the hepatitis C genotype that a person has. In many cases, the preferred option is a 12-week course of the recently approved sofosbuvir (brand name Sovaldi) plus ribavirin and pegylated interferon injections. However, several other options, including combinations that do not include pegylated interferon, are suggested. For example, six different treatment options are recommended for patients with genotype 1 HCV infection, the most common form of hepatitis C in Europe.

Chemsex

Researchers have looked into the practice of ‘chemsex’ (taking recreational drugs such as mephedrone, GHB/GBL and crystal meth during sex) in London.

Some people have expressed concern about this, saying that drug use among gay men in London has reached unprecedented levels and that it is fuelling the transmission of HIV, hepatitis C and other sexually transmitted infections. However, there has been very little reliable research on the topic until now.

The researchers found that drug use was much more common among gay men living with HIV, especially those living in some parts of London, than amongst other gay men. And while many of these men didn’t feel that their drug was problematic, a significant minority said that they were concerned about it.

Many men appreciated drugs’ ability to boost their sexual self-confidence, provide a more intense experience and facilitate more adventurous sex. But some men felt that they had become reliant on drugs and were no longer satisfied with sex when sober. Many respondents said that they weren’t particularly happy with their sex lives, often longing for the intimacy of a long-term partner.

Some men were concerned that they had pushed their sexual boundaries too far or taken risks that they regretted. A few had had an overdose, usually while using GHB/GBL.

Some men had looked for professional help. When it was available, men valued clear, honest and non-judgmental information about how to use drugs and have chemsex safely. Some men had got this from specialised services such as Antidote, the CODE clinic at 56 Dean Street, the Burrell Street sexual health clinic or the mental health charity PACE. The researchers say that more services like these need to be funded and should be more widely available.

Risks for cancer

A new study has shed light on risk factors for cancers. The researchers were particularly interested in those cancers which are sometimes caused by viruses and which are not considered to be AIDS-defining illnesses. These include anal cancer (linked to human papillomavirus, HPV), Hodgkin’s lymphoma (linked to Epstein-Barr, a type of herpes virus) and liver cancer (often caused by hepatitis B or C).

Most people are infected with one of these viruses, but they don’t usually cause problems. And while cancer rates are higher in people with HIV than in the general population, we need to remember that only a minority of HIV-positive people go on to develop cancer.

In this study, in a group of just under 10,000 Americans living with HIV, there were 65 diagnoses of these cancers in around four years of follow-up.

People with a low CD4 cell count were more likely to have cancer. However, what was more important was the way the CD4 count changed after starting to take treatment – people who had a rapid rise in CD4 cell count were less likely to have a cancer later on, while people whose CD4 count did not improve much were at greater risk.

This underlines the importance of good adherence to HIV treatment.

The researchers also recommend that people living with HIV whose CD4 counts stay low after starting treatment should have more frequent screening for these cancers.