HIV update - 24th June 2015

New British guidelines recommend treatment for everyone with HIV

Everyone with HIV who is prepared to take antiretroviral treatment should receive it, regardless of CD4 cell count, new draft British HIV Association (BHIVA) treatment guidelines recommend.

Anyone living with HIV who understands the commitment of treatment and is ready to start should receive treatment, according to the draft guidelines. The decision to start treatment rests with the person living with HIV.

The change from a recommendation to start treatment before the CD4 cell count falls below 350 cells/mm3 to treatment for all follows the results of the START trial, a keenly awaited international study described in the last edition of HIV Update.

The START study showed that starting treatment at a CD4 cell count above 500 cells/mm3 reduced the risk of death or serious illness by 53% compared with waiting to start treatment until the CD4 count fell to 350 cells/mm3. The absolute risk of death or serious illness was small – 3.7% of people in the deferred treatment arm became seriously ill or died, compared to 1.8% in the immediate treatment group over three years of follow-up. Nonetheless, the BHIVA guidelines committee concluded that the evidence now supports offering treatment to everyone prepared to take it.

There are a few situations in which treatment is needed more urgently, with the guidelines recommending that it be started within two weeks. This is the case for people with a CD4 cell count below 200 cells/mm3, an AIDS-defining infection or a serious bacterial infection.

The guidelines also make a shift away from recommending efavirenz in first-line treatment. Doctors should ask people who are already taking efavirenz about sleep and mood, in order to identify people who might benefit from switching to an easier-to-take drug.

The guidelines now recommend that first-line treatment should be based on either an integrase inhibitor, a boosted protease inhibitor, or the new non-nucleoside reverse transcriptase inhibitor rilpivirine.

When drugs are equivalent in terms of efficacy and safety, cost should be a consideration in prescribing. But prescribing on the basis of cost should not be permitted to affect patient outcomes or quality of care.

The draft guidelines are open for consultation and feedback, until 17 July. You can submit comments here.

Living with multiple medical conditions will become the norm

Due to effective HIV treatment, the life spans of people with HIV are ever longer. In the United Kingdom and many other countries, the average age of people living with HIV has been creeping up for several years.

Doctors and researchers are working out what this will mean for the clinical care they need to provide. There are a host of medical conditions which are commonly experienced in older age and which may occur a little earlier in people living with HIV than in other people.

Managing these medical conditions, on top of HIV, will be an important component of healthcare for people living with HIV.

A new study looks at the current healthcare needs of people with HIV in the Netherlands and, based on this, makes predictions for what may be needed in 2030.

  • The proportion of people with HIV over the age of 50 will jump from 28% in 2010 to 73% in 2030.
  • The proportion needing medical care for a condition on top of their HIV will increase from 29% to 84%. 

The extra medical conditions (co-morbidities, in doctors’ language) include high blood pressure, heart disease, diabetes and cancer. However, the researchers weren’t able to take account of some other medical problems because there weren’t any reliable statistics on how common they are at different ages. This includes depression, cognitive impairment, fractures and incontinence. So the figures given may be underestimates.

Half of all people living with HIV will need to take at least one other long-term drug alongside their HIV treatment. Doctors will need to check that these drugs can be safely taken together.

If you are on HIV treatment and you are also taking medicines for another health condition, it’s important to check for drug interactions. Each doctor you see needs to know about all the medicines you are taking. You can find out more about drug interactions in our booklet ‘Taking your HIV treatment’.

Across Europe, four in ten people diagnosed with HIV are migrants

A new study provides an overview of migration and HIV in 29 European countries. Overall, 38% of people diagnosed with HIV were born outside the country they currently live in.

The largest numbers live in the United Kingdom, France, Italy, Spain, Germany, Belgium, Greece and Poland. In most countries of central and eastern Europe, there are few migrants living with HIV.

Half of all migrants come from African countries. However, there has been a steady decline in the size of this group, while HIV diagnoses in people who have moved from central and eastern Europe to western Europe, or from Latin America, Asia and the Middle East have continued. Many of those born in the latter countries are men who have sex with men. 

People born in African, Asian and Latin American countries are much more likely to be diagnosed with HIV late, with a low CD4 cell count. This is partly because European countries have made it increasingly difficult for migrants to access healthcare. The systems are often complex and confusing to navigate, with many restrictions.

However, HIV treatment is free for all HIV-positive people who are living in the UK, regardless of immigration status.

People who go hungry have poorer outcomes

People who don’t have enough food to eat are less likely to have an undetectable viral load than other people living with HIV, according to a study from New York City. This might be because some treatments are difficult to take on an empty stomach, because people in this situation have more pressing priorities than looking after their health, or because treatments may not work so well in people who are under-nourished.

The study also found that people who were in unstable housing or temporary accommodation, and people below the poverty line, were also less likely to do well on HIV treatment. The research shows the importance of projects tackling food shortages and poverty in people living with HIV.

NAM’s ‘Nutrition’ booklet includes advice on eating well on a budget.

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