Switching to generic drugs is saving the NHS money
Around two-thirds of NHS England’s spending on HIV medical care is for antiretroviral drugs, with £429 million spent in 2015-2016. Because people with HIV now have normal lifespans and because the total number of people living with HIV increases each year, the drugs budget would continue to grow if action were not taken.
Across the NHS, around 70% of drugs prescribed are produced by generic manufacturers. As the patents of many anti-HIV drugs have now expired, generic versions of these drugs are now available. They have the same active ingredients as branded drugs, but they are usually cheaper, because there are fewer research and development costs associated with them.
At the recent joint conference of the British HIV Association (BHIVA) and British Association for Sexual Health and HIV (BASHH), Dr Laura Waters outlined an NHS England programme that has tried to reduce spending on antiretroviral drugs in order to preserve funds for other aspects of HIV care. She stressed that the programme was designed by doctors and patient representatives – only clinically appropriate and acceptable switches were recommended.
For example, many people have been taking a pill called Kivexa which contains two drugs, abacavir and lamivudine. This is now available from generic manufacturers, also in a single pill. Switching to this saved £6.9 million in 2016-2017.
Many others have previously taken Atripla, a single tablet treatment containing efavirenz, tenofovir DF and emtricitabine. Efavirenz is now available in generic versions, which can be taken alongside Truvada which contains the other two components. Switching people to this saved £1.1 million.
Faced with the threat of people switching away from Triumeq (dolutegravir/abacavir/lamivudine), its manufacturer lowered the price of the drug in many English regions. As a result, not many people ended up switching.
In the cases just mentioned, the proposed switches were to treatments that contained exactly the same active drugs, but produced by different manufacturers.
Savings were also made by switching people from protease inhibitors boosted with ritonavir to protease inhibitors boosted with cobicistat. The latter are now cheaper and are also available in fixed dose combinations, so there are fewer pills to take. But while ritonavir and cobicistat perform similar functions, this was not a ‘like for like’ switch. Just under £1 million was saved this way.
For most people, the switches did not cause any difficulties. However, the process was not smooth for everyone. Barts Health said that 10% of people who switched to cobicistat subsequently needed to change their treatment, most often switching back to their previous combination. This was usually because of greater side-effects or the size of the new tablet.
The Chelsea & Westminster Hospital reported that 6% of people who switched to generic efavirenz subsequently stopped taking it, usually because of side-effects such as problems sleeping, vivid dreams, depression, dizziness, problems concentrating and headache. As a result of permitted variations in quantities of a drug’s active ingredient and manufacturing differences, some people have different experiences of side-effects when taking different versions of the same drug.
And when people taking Atripla were asked to consider switching, 25% of people ended up switching to a different combination that did not contain efavirenz. Many people used this as an opportunity to review their treatment as a whole. Although they might have previously put up with low-level, long-term side-effects of efavirenz, there’s now more awareness that alternate drugs are available and that efavirenz is no longer a first-line choice for treatment.
Mother-to-child HIV transmission at all-time low in the UK
There are approximately 35,000 women living with HIV in the UK and each year around 1200 become pregnant. Mother-to-child HIV transmission is at an all-time low: between 2015 and 2017, only five infants were born with HIV in the UK.
However, researchers have looked into the circumstances of those rare HIV transmissions, in order to better understand how services can be improved. They analysed a total of 108 cases of mother-to-child transmission that happened between 2006 and 2013 (a period when the number of transmissions was a little greater).
In two-thirds of these cases, the mother was only diagnosed with HIV after delivery. This was often because she had acquired HIV during pregnancy or had refused HIV testing during pregnancy. Among women who had previously been diagnosed with HIV, many did not attend healthcare services regularly or did not take HIV treatment consistently.
The underlying reason for this is likely to be adverse social circumstances, which were recorded for over half the women. These included uncertain immigration status, housing problems, domestic violence, involvement of social services, mental health issues, lack of fluency in English and drug/alcohol abuse.
Clinics need to continue to support women with these difficulties, in order to help them engage with care and adhere to HIV treatment, the researchers say.
For more information, read 'Pregnancy and birth' in NAM's booklet 'HIV & women'.
Fewer cancers in people with HIV, but which ones?
Between now and the year 2030, cancer diagnoses in Americans living with HIV are expected to fall by 17%. There have been significant declines in most cancers in the last few years, including anal cancer, lung cancer and colon cancer, and these trends are expected to continue.
But the biggest change is 80% fewer cancers that are described as ‘AIDS defining’. These cancers – including Kaposi’s sarcoma and non-Hodgkin lymphoma – are much more likely to develop when people with HIV have very low CD4 counts. Thanks to people starting HIV treatment promptly, these cancers are expected to affect far fewer people.
Nonetheless, the risk of having a cancer increases with age and people living with HIV are getting older. The proportion of Americans with HIV who are over the age of 65 will increase from 8% in 2010 to 21% in 2030. As a result, many of the cancers which affect people living with HIV are expected to be the same ones which affect other older people. In particular, prostate cancer is expected to become the most common cancer in people living with HIV.
The total number of cancers among Americans living with HIV will decrease from 8150 cases in 2010 to 6690 cases in 2030. In the latter year, this is expected to include 1590 cases of prostate cancer, 1030 of lung cancer and 450 of anal cancer.
People with HIV are not generally thought to be at greater risk of skin cancers than other people. However, a new Danish study suggests that they could be at greater risk of two of the three main types of skin cancer.
There are three major types of skin cancer — basal cell carcinoma, squamous cell carcinoma and melanoma. You can reduce your risk of skin cancer by limiting or avoiding exposure to sunshine and the lights used in tanning beds. It’s possible that having a suppressed immune system may increase the risk of skin cancer.
Skin cancers are usually treated with surgery. The cure rates of basal cell carcinoma and squamous cell carcinoma are very high; treatment for melanoma is usually successful if the cancer is spotted at an early stage.
The Danish researchers compared the risk of skin cancer in people living with HIV and people of the same age and sex in the general population. They also looked at cancer rates in the brothers and sisters of people living with HIV, who are expected to have a similar skin type and to have been exposed to a similar amount of sunshine in childhood.
Basal cell carcinoma is the most common form of skin cancer (14 cases in a group of 1000 people in the general population followed for ten years) and rates were higher in people with HIV (24 cases in a group of 1000 people followed for ten years). However, this difference was only seen in gay men. One plausible explanation is that, in adult life, gay men expose themselves to the sun and use tanning beds more than other people.
The rate of squamous cell carcinoma was also lower in the general population (1 case in a group of 1000 people followed for ten years) than in people living with HIV (5 cases). It does appear that damage to the immune system is a factor – people with HIV who had had very low CD4 counts in the past were at greater risk.
In relation to melanoma, there was no difference in the rate between those with and without HIV.
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