In this edition of HIV Weekly you can read about side-effects, HIV/hepatitis C coinfection, and HIV and lung cancer.

Side-effects of anti-HIV treatment

Heart disease

Taking potent anti-HIV treatment can mean a longer, healthier life. But anti-HIV drugs can also cause unwanted side-effects. It is now well known that some anti-HIV drugs can cause increases in blood fats and sugars and that this can lead to an increase in the long-term risk of heart disease.

Danish doctors have conducted a study to see if people taking anti-HIV treatment have an increased risk of developing a type of heart disease called ischaemic heart disease. This type of heart disease involves a reduced supply of blood to the heart.

They found that taking HIV treatment involved the same risk of developing this type of heart disease as smoking between one and four cigarettes a day. 

They also found that people taking anti-HIV treatment who were admitted to hospital with ischaemic heart disease were much more likely than HIV-negative people with the same condition to die within 30 days.

What’s more, they found that the risk of ischaemic heart disease appeared soon after people started taking HIV treatment, but did not increase the longer a person took anti-HIV therapy.  Heart disease is often caused by the hardening of the arteries. This normally takes many years, even decades to develop. The Danish doctors speculate that the increased risk of heart disease seen in people starting HIV treatment could be due to other factors, such as inflammation of certain blood cells, or the restoration of the immune system.

US researchers recently found that the risk of heart disease was doubled in people with HIV, and was trebled in HIV-positive women compared to the general population. They recommended that all HIV-positive people should have their risk of heart disease assessed.

Stopping smoking, eating a good diet, and taking exercise can all significantly reduce the risk of heart disease.

Diabetes drug causes concern

HIV-positive people have a higher risk of developing diabetes. It is thought to be a possible side-effect of anti-HIV treatment, but one study also suggests that HIV infection itself may be a risk factor for the condition.

Some HIV-positive people with diabetes take a drug called rosiglitazone.  Studies have shown that it can be an effective treatment for the metabolic disturbances that some anti-HIV treatment can cause.

But an analysis of studies looking at the use of rosiglitazone has found that its use increases the risk of heart attack and slightly increases the risk of dying of heart disease.

Researchers looked at a total of 42 different trials. These trials involved over 15,000 people taking rosiglitazone and just over 12,000 people taking a comparator treatment. A total of 86 heart attacks were recorded in people taking rosiglitazone compared to 72 amongst those taking other drugs. There were 39 deaths from heart disease in the rosiglitazone group compared to 22 in the other group.

The makers of rosiglitazone, GlaxoSmithKline, have pointed to other evidence showing that large studies found no increased risk of heart attack amongst people taking the drug.

US drug regulatory authorities are planning a special meeting to look at the safety of rosiglitazone, and in the meantime have advised people taking the drug, particularly those with an underlying cause of heart disease, to discuss the new information about the drug with their doctor.

Promising new treatment for facial wasting

Two anti-HIV drugs, d4T (stavudine, Zerit) and AZT (zidovudine), have been associated with the wasting of fat from the face, limbs and buttocks. Because of these side-effects, UK HIV treatment guidelines now recommend that the use of these drugs should be avoided if there are other treatment options available.

Facial fat wasting can be a highly distressing side-effect as it is stigmatising, and has been shown to cause a loss of self-confidence and mental health problems such as depression.

Cosmetic treatment for facial wasting is available. The most widely used is called New Fill. A substance called polylactic acid is injected into the affected areas. It has been shown to improve appearance and cause few side-effects.

Another treatment being researched is called polyalkylimide gel (Bio-Alcamid). Like New Fill it is injected into the affected areas.

A small study has found that this treatment is an effective and safe treatment for facial wasting. The only side-effects were temporary redness, bruising and pain in the injection areas. The injections improved both the appearance of facial wasting and quality of life.

HIV and hepatitis C coinfection

International guidelines for the treatment of HIV and hepatitis C coinfection

Many people with HIV are also infected with hepatitis C virus. This is called HIV/hepatitis C coinfection and being coinfected can have important implications for the way in which both HIV and hepatitis C are treated.

The British HIV Association, the professional organisation of the UK’s HIV doctors has a set of guidelines for the care and treatment of people with HIV and hepatitis C. You can read the full guidelines here, and NAM’s HIV and hepatitis booklet provides a summary here.

There are also international guidelines for the treatment of people who have HIV and hepatitis C. These have just been updated.

The issues covered by the guidelines include:

**Optimal dosing and duration of therapy: Ribavirin should be dosed according to a person’s weight. All coinfected patients should receive a year of anti-hepatitis C treatment, but people who have a slower response to treatment might need an extra three or six months therapy.

**Predicting response to anti-hepatitis C treatment: An undetectable hepatitis C viral load after four weeks of treatment is the best predictor of a successful treatment response.

**Treatment for non-responders and relapsers: Hepatitis C therapy is often unsuccessful in people with HIV. The guidelines make recommendations on how these people can be best managed. These include long-term use of interferons or the use of experimental treatment such as hepatitis C protease inhibitors.

**Treating acute hepatitis C: The guidelines note that there have been outbreaks of hepatitis C amongst gay men in Europe, linked to sexual transmission. Providing anti-hepatitis C treatment soon after these men were infected has been associated with an improved treatment-response.

**Assessment of fibrosis: Blood tests, ultrasounds and scans can be used to see how much damage hepatitis C has done to a person’s liver. These are as accurate as liver biopsies.

**Anti-HIV treatment and liver side-effects: AZT and ribavirin should never be used together because this can lead to very serious side-effects. The drugs ddI, d4T and nevirapine should also be used with caution in people with hepatitis C as they can harm the liver. The guidelines also suggest that HIV treatment should be started earlier in people with coinfection.

HIV/hepatitis C coinfected patients have a poorer response to HIV treatment

American researchers have found that HIV/hepatitis C coinfected patients do less well on HIV treatment than people who only have HIV.

They looked at CD4 cell counts and CD4 percentages in patients who were 100% adherent to their HIV treatment. They found that even though viral load did not differ, both CD4 cell count and CD4 percentage were significantly lower amongst coinfected patients.

The researchers suggest that both anti-hepatitis C treatment and anti-HIV treatment should be commenced early in order to have the best chance of success.

Lung cancer

American researchers have found that people with HIV have an increased risk of dying from lung cancer, and they found that these risk couldn’t be entirely explained by smoking.

Lung cancer is not considered an AIDS-defining cancer, although there is increasing evidence that the cancer is seen more often in people with HIV. It has been suggested that the increased risk of lung cancer seen in people with HIV is largely because people with HIV are much more likely to smoke.

Researchers in Baltimore have now found that HIV-positive injecting drug users were much more likely to die of lung cancer than HIV-negative injecting drug users. Smoking was almost universal in both groups, but smoking alone could not explain the increased risk of lung cancer observed in people with HIV.

People with HIV are more vulnerable to lung disease and the researchers found that those with lung problems such as asthma were more likely to develop lung cancer.

The findings of this study are very similar to those of another American study published earlier this year. It too found that people with HIV had an increased risk of lung cancer and that smoking alone couldn’t explain this. The researchers in that study speculated that chronic lung disease could cause long-term inflammation that could increase the risk of cancer.

Living with HIV – you might be able to help the British Library

From 1995 to 1999 the 'HIV and AIDS Testimonies Project' recorded life history interviews with 30 people infected with the virus living in the UK. These are kept unedited in the Sound Archive at the British Library as both part of a record of our social history and as a research resource for the future (respecting the wishes of those who gave them - some are completely closed for 50 years). All interviewees also received a copy to keep for themselves, their friends and family. 

As part of a 2007 follow-up project, ten new interviews are being conducted with people living with HIV in the UK, who have been infected in the last decade or who were unable to tell their story ten years ago. At the moment, the British Library are looking for people who want to take part who are from African Communities, who are gay men under 25 years of age, or who are young people born with the virus. They would also particularly like to find some people who live outside of London, perhaps in Manchester, Edinburgh, the Midlands or in a rural location. 

Offering to be interviewed involves being visited by a trained oral historian who will record your story in your own words over a number of sessions. Please get in touch with the project (not NAM) if you would like to find out about taking part. The Project is based at London South Bank University. 

For further information, please ring Wendy Rickard on 0207 815 8467 or email rickarwj@lsbu.ac.uk.

copy of 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.

You can also download them at:

http://www.aidsmap.com/cms1187580.asp

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.