Cotrimoxazole to prevent infections
The antiobiotic cotrimoxazole is currently recommended by the World Health Organization for anyone with HIV who has a CD4 count below 350 in low and middle-income countries. It is also recommended for anyone with HIV who has serious symptoms such as an opportunistic infection, TB or wasting disease, regardless of CD4 cell count.
It is also recommended for children with HIV, and after four to six weeks of age for infants whose HIV status has not been confirmed yet.
Cotrimoxazole reduces the risk of developing a number of serious illnesses and infections, including pneumocystis pneumonia, toxoplasmosis, malaria and a range of life-threatening bacterial infections.
The antibiotic is taken once a day and rarely causes serious side-effects. Taking a medicine to prevent an infection is called prophylaxis.
Several studies have now shown that in people who start taking antiretroviral therapy, cotrimoxazole still reduces the risk of death, because it reduces the risk of developing serious illnesses.
A study in South Africa has now shown that even in an area where malaria is uncommon and where lots of bacteria are resistant to cotrimoxazole, taking cotrimoxazole after starting ART still reduced the risk of death by 36%, regardless of CD4 cell count.
The benefit was greatest in people who started treatment when they had a CD4 count below 200, and in those with higher CD4 counts who already had serious HIV-related illnesses.
Another recent study in Uganda and Zimbabwe showed that taking cotrimoxazole halved the risk of dying during the first year and a half of antiretroviral treatment.
The antibiotic also reduces the risk of death when taken alongside TB treatment by people with HIV, and halved the risk of death in infants and children with HIV not receiving antiretroviral therapy.
For all these reasons, cotrimoxazole should be offered to adults and children with HIV with low CD4 counts living in low and middle-income countries, whether antiretroviral treatment is being taken or not.
Hepatitis B vaccination
Hepatitis B is a virus that is transmitted in similar ways to HIV. Therefore large numbers of people with HIV are also co-infected with hepatitis B.
Liver disease caused by hepatitis B is an important cause of illness and death in co-infected patients.
There’s a very effective vaccine against hepatitis B and it’s recommended that everybody with HIV should receive this vaccination (unless they are naturally immune – a test can tell this).
A new study in the general US population has shown that the vaccine has helped to reduce prevalence of hepatitis B there. The US has a policy of vaccinating children against hepatitis B, as well as individuals at increased risk of the infection, for example gay men and injecting drug users.
The study compared prevalence of the infection in the period 1988-1994 to prevalence in 1999-2007.
There was a big fall in the proportion of children and young adults with the infection.
Prevalence didn’t change in older adults. The study also showed there was a higher prevalence of the infection in some groups, including African Americans and migrants.
In the UK, hepatitis B vaccinations are available for free from sexual health and GUM (genitourinary medicine) clinics.
The vaccine is provided in a course of three injections, is very safe and works well in people with HIV. After a few years, it may be necessary to have a booster, and your regular HIV care should include regular tests to monitor your immunity to the infection.
Hepatitis C and insulin resistance
Many people with HIV are also co-infected with hepatitis C.
Although hepatitis C can be treated, the therapy doesn’t always work, and only about a third of people with HIV who have had hepatitis C for a long time clear the virus after completing this treatment.
Researchers are trying to find ways of improving the response of people with HIV to hepatitis C therapy.
Their research involved 134 patients who, between 2000 and 2007, were treated with ribavirin and interferon.
They looked at the factors associated with successful hepatitis C therapy (a negative hepatitis C viral load, six months after the completion of 48 weeks of treatment, an outcome that is often described as a ‘sustained virological response’).
Analysis showed that patients who didn’t have insulin resistance were about three times more likely to have a sustained virological response than patients who had insulin resistance.
This finding was unaltered when the investigators took into account factors such as age, gender, body mass index, type of interferon used in therapy, and fibrosis stage.
Your ability to process sugar can be easily monitored, and if you have insulin resistance, it’s often possible to do something about it.
CD4 cell count and viral load
Your routine HIV care will involve a number of blood tests to see how the virus is affecting your health.
Two of the most important tests are CD4 cell count and viral load.
Your CD4 cell count gives a rough idea of the health of your immune system, and your viral load shows how active HIV is within your body.
If you’re not taking HIV treatment, it’s usual for your CD4 cell count to gradually decline. However, the viral load of many people remains steady until it increases shortly before they become very ill with HIV and develop an AIDS-defining illness.
The viral load test monitors the amount of HIV in blood. Other tests can monitor the amount of virus in cells.
They monitored patients who were not taking HIV treatment and who were not ill because of HIV.
Their research showed that, as expected, there was a fall in the patients’ CD4 cell counts.
However, viral load in their blood did not increase.
But falls in CD4 cell counts could be correlated with increases in viral load in cells.
There were only ten patients in the study, so the researchers are calling for more research to see how reliable their findings are.