HIV update - 17th September 2014

Atripla or separate pills?

HIV treatment usually involves taking a combination of three or four different anti-HIV drugs. But more than one drug may be combined into a single tablet, which may make it easier to take.

For example, a tablet called Atripla combines three drugs which can also be taken as separate pills – tenofovir, emtricitabine and efavirenz. Whether the drugs are taken separately or as Atripla, they should be taken once a day. But doctors disagree on whether people are more likely to take their HIV treatment in the right way (often called ‘adherence’) if the numbers of pills is reduced in this way.

A new analysis has re-examined data from previous studies to see whether people have better results when they are prescribed the single-tablet regimen Atripla, compared to people given the three component drugs as separate pills.

In terms of ‘virological failure’, in other words viral load that was not undetectable, results were the same, regardless of the number of pills a person was taking. Virological failure happened to around one-in-five people.

But there was a difference in the time to virological failure. When it happened, it occurred quicker to people taking separate pills (average seven months after starting treatment) than to people on Atripla (average twelve months). In addition, those prescribed separate pills were more likely to have drug-resistant virus than those on Atripla.

This isn’t the first study to look at whether results are better when people are taking fewer pills. For example, we’ve reported on other studies in October 2012, October 2013 and February 2014. Different studies have looked at different kinds of outcomes – including having an undetectable viral load, taking pills regularly and needing to go to hospital – and the results have varied. But several have shown slightly better results when fewer pills are taken.

On the other hand, pharmaceutical companies sometimes charge the NHS a much higher price for tablets which combine several drugs in one, such as Atripla. Giving patients the same drugs but in separate pills usually costs less money. This is especially the case when the separate pills are available from other pharmaceutical companies as generic drugs.

NHS doctors and managers need to decide whether the benefits of the more expensive versions are worth the extra expense.

Recreational drugs

Results from a large study of recreational drug use and sexual risk in HIV-positive gay men have been released. Over 2200 men were recruited from HIV clinics in London, Brighton and Manchester. These men had been diagnosed for an average of ten years and most were taking HIV treatment.

Half the men had used recreational drugs in the past three months. While poppers and cannabis were the most widely used drugs, men who had used several different drugs reported a wide range of substances, including cocaine, Viagra, ketamine, MDMA, GHB/GBL, crystal methamphetamine and mephedrone. A quarter of respondents had used three or more substances.

Men who used more drugs were more likely to report a number of different sexual behaviours, including any sex at all, sex without a condom, group sex, ten or more recent sexual partners and being diagnosed with a sexually transmitted infection (STI).

For example, 24% of men who didn’t use recreational drugs had had sex without a condom, rising to 33% of those who had used one drug, 53% of those who had used three drugs and 78% of those who had used five or more drugs.

The study also used a careful definition of high-risk sex which could transmit HIV – sex without a condom, with a partner who wasn’t known to have HIV, while either not taking HIV treatment, with a detectable viral load or with an STI. A small minority of men engaged in this behaviour, but the proportion did rise with increasing drug use – 4% of those not using drugs, 7% of those using one drug, 11% of those using three, and 16% using five or more recreational drugs.

Men who used crystal methamphetamine were three times more likely than non-drug users to report sex which could transmit HIV. This drug appears to have a disinhibitory effect that is distinct from the effect of other drugs.

The researchers say that more help needs to be available from HIV clinics and drugs services to help men having difficulties with their drug use. Specialised services such as Antidote, the CODE clinic at 56 Dean Street, the Burrell Street sexual health clinic and the mental health charity PACE are available, but staff at many HIV clinics have experience in supporting people with these issues.

HIV testing up among African people

Data from surveys of African people living in England suggest that the proportion of people who have tested for HIV has increased over the last five years. In the most recent survey, two-thirds of those who took part had taken a test, many of them in the past year. While the people who take part in surveys like this are not completely representative of the wider African population in England – these figures are probably over-estimates – the numbers have improved since the last survey in 2008.

This is very important for improving the health of African people living with HIV in England. Because people don’t test for HIV often enough, many people are diagnosed with HIV very late (after the immune system has been weakened and the CD4 count is low). HIV treatment works best when it is started early.

The survey also found improvements in African people’s knowledge about HIV testing and treatment. For example, more people know where to take a test and understand the benefits of HIV treatment. But three-quarters of those completing the survey did not know that 1 in 20 Africans in the UK have HIV. At the same time, many African people who had never taken an HIV test said that this was because they “had no reason to think they had HIV”.