Scepticism about the ‘elimination’ of HIV, but nevertheless, some reasons to be optimistic

Last week a study was published suggesting that it might be possible to eliminate pools of HIV-infected cells with eight years of HIV treatment. This hopeful conclusion was based on the results of a study involving seven patients who started HIV treatment soon after they were diagnosed with HIV. Other researchers, however, are much more sceptical. You can read details of the study and responses to it below.

But, even if we don’t have HIV treatment that is able to eliminate HIV, there’s now good evidence to show that the risk of dying of AIDS five years after starting HIV treatment is less than 1% for many.

Yet, as other items in this week’s edition make clear, side-effects, coinfections and mental health problems really do have an impact on the lives of people with HIV.

Causes for optimism yes, but tempered by realism.

Anti-HIV treatment

Elimination of HIV?

Taking anti-HIV therapy can mean a longer, healthier life, but the currently available antiretroviral drugs cannot cure HIV. Some doctors are hopeful that taking potent anti-HIV drugs will enable a person with HIV to live a normal, or near normal, life-span and one recent study suggested that a person diagnosed with HIV in their mid-20s would live to their mid-60s if they took currently available HIV drugs. This estimate didn’t take into account the likely availability of better drugs in the future, so many doctors believe that the prognosis of people with HIV is even better than this study suggests.

Although currently available anti-HIV therapy can lower the amount of HIV in the blood (usually called viral load) to levels that are so low they are undetectable using the currently available tests,  it cannot eliminate so-called reservoirs of resting HIV-infectedCD4 cells.

But the results of a small American study suggest that if HIV treatment is started soon after a person first becomes infected with the virus, the pool of HIV-infected CD4 cells could be eliminated within eight years.

The study involved seven people who started potent anti-HIV treatment within an average of seven months of their infection with HIV. These patients were monitored for an average of 40 months, and all achieved and maintained an undetectable viral load in their blood.

Further tests were performed to see how fast the pool of resting, HIV-infected, CD4 cells declined. These showed a decline of 50% every six months, leading the researchers to calculate that it would take just under eight years for the complete elimination of these cells.

More studies are planned by the researchers. In these they plan to use the integrase inhibitor raltegravir and the fusion inhibitor enfuvirtide (T-20) to speed up the rate at which viral load initially falls in the hope that this will accelerate the decay of the pools of the latently infected cells..

But others are urging caution, pointing out that in over 50% of patients in the study, the pool of latently infected cells fell at a much slower rate than the headline figure. This could mean that enough HIV-infected cells remained to “re-ignite” HIV infection.

Tool to calculate prognosis

An international team of researchers have updated their online tool that enables people starting HIV treatment to calculate their risk of disease progression and/or death for five years after starting HIV treatment. It will soon be available online here.

The researchers looked at the outcomes of over 20,000 people starting HIV treatment to develop this resource.

Five factors were used to calculate the prognosis of people starting HIV treatment: age, CD4 cell count, viral load, injecting drug use, and an AIDS diagnosis before HIV treatment was started.

They found that the people with the lowest risk of progression to AIDS or death five years after starting anti-HIV treatment were the under 30s, who had a CD4 cell count above 350 and a viral load below 100,000, who didn’t inject drugs, and who had not progressed to AIDS.

A second set of calculations was also performed by the researchers to see if they could predict who had the greatest risk of HIV disease progression after six months of HIV treatment. According to this model,  those under 50s who did not inject drugs, whose CD4 cell count increased to 350, and viral load fell to below 500 had a very low risk of developing AIDS or dying over five years. Their risk of dying was calculated to below 1%.

Side-effects

Although taking anti-HIV drugs can mean a longer, healthier life, they can cause unwanted side-effects.

Lipodystrophy is a set of side-effects that includes increases in blood fats and sugars and changes in body fat shape. Some people experience an accumulation of fat around the belly or at the back of the neck.  Others experience fat loss from the limbs, buttocks, and face, and some people experience a combination of both fat accumulation and fat loss.

Now doctors are suggesting that another kind of fat change might also be a symptom of lipodystrophy – fatty swellings in the pelvic region, or pubic lipomas.

Doctors in Italy checked their HIV-positive patients for lipodystrophy. They found that the risk of having pubic lipomas increased if a person was seriously overweight, and that those who had fat accumulation between the shoulders or at the back of the neck (so-called ‘buffalo hump’) were also more likely to have pubic lipomas.

Mental health

Higher rates of depression have been observed in people with HIV, indeed one survey of people with HIV in the UK found that around two-thirds said that they’d felt depressed at sometime in the previous year.

Now a study has found that 20% of HIV-positive people said they had thought seriously about suicide in the previous week. However, the study also found that very few of these people actually have plans to kill themselves or would kill themselves if they had the opportunity.

It’s worth noting that treatments for depression work well in people with HIV, and if you are depressed or thinking of harming yourself make sure that you ask your HIV clinic doctor or GP for help. It is available, and it will make a difference.

HIV and hepatitis C

Many people with HIV are also infected with hepatitis C virus. This is usually referred to HIV/hepatitis C coinfection.

Hepatitis C is transmitted by contact with hepatitis C-infected blood. In recent years, there have been reports of sexual transmission of hepatitis C, most notably in HIV-positive gay men.

Delegates to the recent conference of the British HIV Association (the professional organisation of the UK’s HIV doctors), were presented with data showing that one out of every 83 HIV-positive gay men in London and Brighton is newly diagnosed with hepatitis C each year.

Delegates were also told that some coinfected patients who have had hepatitis C infection for a long time were being diagnosed as having ‘acute’ or recent hepatitis C infection because they suddenly developed antibodies to the infection. The preferred method of testing for hepatitis C is viral load, or PCR testing.

Diagnosing hepatitis C

Many people with HIV are also infected with hepatitis C virus. This is usually referred to HIV/hepatitis C coinfection.

Hepatitis C is transmitted by contact with hepatitis C-infected blood. In recent years, there have been reports of sexual transmission of hepatitis C, most notably in HIV-positive gay men.

Delegates to the recent conference of the British HIV Association (the professional organisation of the UK’s HIV doctors), were presented with data showing that one out of every 83 HIV-positive gay men in London and Brighton is newly diagnosed with hepatitis C each year.

Delegates were also told that some coinfected patients who have had hepatitis C infection for a long time were being diagnosed as having ‘acute’ or recent hepatitis C infection because they suddenly developed antibodies to the infection. The preferred method of testing for hepatitis C is viral load, or PCR testing.

HIV/hepatitis C coinfection and the risk of HIV treatment side-effects

It is well known that some anti-HIV treatments can involve a risk of lipodystrophy and diabetes.

Two recent studies looked at these complications in people who were coinfected with HIV and hepatitis C.

American researchers have found that there is at worst a “weak” association between HIV/hepatitis C coinfection and the risk of diabetes in people who are not taking anti-HIV treatment. They found that the factors associated with diabetes were traditional risk factors, such as ethnicity, age and being over-weight.

Researchers have also found that HIV/hepatitis C coinfected patients who are taking anti-HIV treatment do not have an increased risk of lipodystrophy. A study found that fat loss was associated with the use of certain anti-HIV drugs, particularly d4T (stavudine, Zerit), but that coinfection did not increase the risk of fat loss. Indeed, they found that coinfected patients taking d4T actually experienced less fat loss than patients who only had HIV.

Tuberculosis

Tuberculosis (usually shortened to TB) is the biggest cause of illness and death in people with HIV around the world. It is also one of the most common AIDS-defining illness seen in the UK.

Taking a combination of antibiotics normally for six months (although some patients may require a longer course of treatment) can cure TB, even if a person has HIV. But TB can become drug-resistant. TB that is resistant to two key drugs, isoniazid and rifampicin, is said to be multidrug-resistant TB (MDR-TB). It is harder to treat and is associated with an increased risk of death.

Recently, there has been a lot of concern about the emergence of strains of TB that have resistance not only to first-line drugs, but also a number of second-line drugs as well. Doctors call this extensively drug-resistant TB (XDR-TB) and many of the cases seen so far have involved people who are HIV-positive. There is a lot of concern about XDR-TB as people who have it become very ill, very quickly, and usually die. Good infection control, like opening windows in hospitals can help reduce the risk of TB, even XDR-TB, being passed on between patients.

Extremely drug-resistant TB (XXDR-TB) has resistance to every anti-TB drug, and doctors in Italy have reported two cases.  Both the patients, who were HIV-negative, died.

XXDR-TB emerged in these patients because they did not receive the right anti-TB treatment from their doctors. The provision of ‘sub-optimal’ TB treatment is one of the main reasons why drug-resistant TB has become such a problem around the world.

But drug-resistant TB can also develop if a person does not take their treatment properly. Anti-TB treatment normally involves four antibiotics for the first two months, with treatment for four more months with two antibiotics. As with HIV treatment, some people miss doses, allowing resistance to emerge. In addition, symptoms of TB often disappear after a few weeks of anti-TB treatment and some people assume that this means that they have been cured and so stop their treatment. This allows drug-resistant TB to develop.  It is therefore essential to take the full course of TB treatment.

Mother-to-child transmission of HIV

Testing babies for HIV infection

It is possible to reduce the risk of mother-to-child transmission of HIV to very low levels by using anti-HIV drugs, appropriately managing labour, and, in the UK and similar countries, where safe alternatives are available, by not breastfeeding.

The HIV antibody test is the method normally used to detect HIV infection. But the way that babies are tested to look for HIV infection is different. Babies can be uninfected with HIV, but still have their mother’s antibodies to HIV for up to 18 months after they are born. Because of this, the babies of HIV-positive mothers do not have an HIV antibody test until they are at least 18 months old. Instead, doctors use three viral load tests during the first six months of a baby’s life to see if it has been infected with HIV.

Doctors are now reporting that newer, more sensitive HIV antibody tests, are producing ‘false-positive’ results in HIV-negative babies, even when they are tested 18 months or so after birth. They believe that this is because these tests are still able to detect the mother’s antibodies. They therefore recommend that older, less sensitive antibody tests should continue to be used on babies. They also suggest an additional viral load test should be performed after six months to provide reassurance that the baby is not infected with HIV.

Blood disorders in babies exposed to HIV drugs

German researchers have found that babies exposed to HIV drugs in the womb or just after birth often develop a shortage of red blood cells (anaemia), or a shortage of white blood cells (neutropenia).

The babies in the study were treated with AZT. Although this drug is known to be effective at preventing mother-to-child transmission of HIV, it is known to cause anaemia.

The researchers stress the benefits of anti-HIV treatment to prevent mother-to-child transmission of HIV, but also emphasise that infants exposed to anti-HIV drugs need to be closely monitored to see if they have experienced any side-effects. 

New from NAM

Criminal HIV transmission

This new title from NAM provides evidence-based, up-to-date information in clear, layman’s language on aspects of HIV that may relate to the investigation, prosecution, and defence of criminal HIV exposure/transmission cases.

It’s primarily aimed at people who work within, or are in contact with, the criminal justice system. But the book is also likely to be useful for those who work at HIV support organisations, as well as HIV-positive individuals with an interest in criminal HIV transmission.

The book cost £14.95 for professionals, but is available at the discounted rate of £9.95 to voluntary organisations.

For more information or to order a copy of the book, please contact NAM by phoning 0207 8400050 or emailing info@nam.org.uk

Booklets

NAM's information booklets anti-hiv drugs, hiv & mental health, hiv & hepatitis and hiv & women have recently been updated.

Please order your free copies today.

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Please note we do charge professionals for these booklets, but don't forget, if your clinic is giving them out to patients you can order them for free. Overseas postage costs apply To find out more email info@nam.org or phone 020 7840 0050.