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Anti-HIV treatment

When to start HIV treatment

Taking potent anti-HIV treatment can mean a longer, healthier life. But potent antiretroviral therapy has only been around for a decade or so and doctors are still learning about the best way to use it.

One issue that is still being debated is when HIV treatment should be started. Opinions on this have shifted over the years. It is currently recommended that anyone who is ill because of HIV should start anti-HIV treatment. It is also recommended that people who have a very real risk of becoming seriously unwell with an HIV-related illness (indicated by a CD4 cell count of 200 or below) should start taking a potent combination of anti-HIV drugs.

But some doctors are now arguing that a person’s chances of doing well on HIV treatment in the long term will be increased if they start taking HIV treatment when their CD4 cell count is higher. They also argue that newer HIV drugs are far less toxic and more powerful than earlier drugs. As a result, starting treatment earlier wouldn’t involve too great a risk of side-effects or drug resistance.

Further weight to the argument that HIV treatment should be started sooner than is currently recommended comes from a Dutch study. It found that, after seven years of HIV treatment, people who started HIV treatment when their CD4 cell count was above 350 were much more likely than those who started with a CD4 cell count between 200 – 350 to experience a restoration of their immune system to normal levels.

Only 46% of those whose CD4 cell count was between 200 – 350 when they started HIV treatment had a CD4 cell count of 800 or above after seven years of treatment. This is compared to almost three-quarters of those who started treatment with a CD4 cell count above 350.

An editorial comment accompanied the study. It said “newer regimens tend to be simpler and safer. This progressively opens the door for a broader re-evaluation of the ideal time to start therapy, incorporating outcomes other than survival, such as the level of immune reconstitution demonstrated [in the Dutch study].”

Side-effects of anti-HIV treatment - diabetes

All medicines have unwanted side-effects and the drugs used to treat HIV can cause side-effects in both the short- and long-term. Some of the long-term side-effects of anti-HIV drugs can involve a risk of other potentially serious illnesses such as heart, liver or kidney disease.

Furthermore, there is good evidence that some anti-HIV drugs can increase the long-term risk of diabetes. It had been thought that protease inhibitors involved the greatest risk of diabetes.

But a Swiss study has found that other classes of anti-HIV drug in particular combinations may also increase the risk of diabetes. The drug combinations most associated with a diabetes risk were 3TC (lamivudine, Epivir) and d4T (stavudine, Zerit); ddI (didanosine, Videx) and d4T; and, tenofovir (Viread) and d4T.

The researchers also found that people of African or Asian origin had a higher-risk of diabetes (African race, along with male sex, older age and being over-weight are all well-known risk factors for diabetes, even if a person isn’t taking HIV drugs).

They were particularly concerned by their findings as the 3TC-d4T combination is widely used in fixed-dose HIV treatment combinations in Africa. Given that African people may be naturally more likely to develop diabetes, the researchers express concern about “the long-term tolerability of anti-HIV treatment in regions that are most affected”.

Anybody can reduce their risk of diabetes by eating a diet that contains a lot of fresh fruit and vegetables and not too much alcohol, sugar or fat. A good place to find out about nutrition is NAM’s booklet on the subject. Not smoking and exercising can also help to reduce the risk of diabetes, heart disease and some cancers.

Side-effects of anti-HIV treatment – liver disease

Having a healthy liver is important for everybody, but it is especially so for people with HIV. This is because the liver plays an important role in processing many of the medicines used to treat HIV as well as some of the other infections that people with HIV are vulnerable to.

Liver disease is one of the biggest causes of illness and death in people with HIV. There are a number of reasons for this. People with very weak immune systems are vulnerable to some liver-related problems. Infections such as hepatitis B or hepatitis C are also a major cause of liver disease in people with HIV.

Drugs, including medicines used to treat HIV, can also cause side-effects that affect the liver. If you’re taking anti-HIV drugs (as well as certain other medicines) your doctor should regularly test your blood to monitor the health of your liver – these tests are called liver function tests. 

Recently, doctors have reported some cases of serious liver disease in people with HIV. But these people didn’t have hepatitis B or hepatitis C, and nor were they heavy drinkers. As the cause of these patients liver problem was unknown the term used to describe it is cryptogenic liver disease.

One French study published earlier this year found that many people with cryptogenic liver disease had a rare liver problem called nodular regenerative hyperplasia. All the patients who had this disease were taking the anti-HIV drug, ddI.

Two other studies presented to a recent conference on HIV and hepatitis also looked at cryptogenic liver disease in people with HIV.

Doctors at London’s Chelsea and Westminster Hospital identified twelve cases of the condition between 2004 – 2007 in their patient population of 4,500. They found that no single anti-HIV drug could be linked to the illness. However, nine of the patients with cryptogenic liver disease had been taking ddI for an average of just under six years. Cases were seen in both men and women, and in Africans and Caucasians, so it didn’t appear the gender or race were important risk factors.

A separate study was conducted by Spanish and Italian doctors. They found 32 cases of the condition in 3,200 people taking anti-HIV treatment between 2004 and 2006. Once again, ddI was the most commonly used anti-HIV drug. The average amount of time people had been taking this drug was a little under four years.

However, most of the cases (27) involved gay men and the researchers speculated that an infectious cause could also be contributing to the illness.

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HIV and hepatitis

Hepatitis B

Hepatitis B is a virus that affects the liver. Since it is transmitted in ways very similar to HIV – through sex and by contact with blood many people who have HIV also have hepatitis B.

There is a highly effective vaccine against hepatitis B and everybody who is HIV-positive should receive this vaccine. The vaccine’s effectiveness should also be monitored at regular intervals to see if a booster dose is required.

Treatment is available for hepatitis B and some of the drugs used in anti-HIV therapy are also effective against hepatitis B. These drugs are 3TC (lamivudine), FTC (emtricitabine, Emtriva), and tenofovir (Viread). It is recommended that people taking anti-HIV treatment who also have hepatitis B should take drugs that work against both viruses.

Although tenofovir has not been formally approved as a treatment for hepatitis B, many doctors use it in this way. At the recent HIV and hepatitis workshop, doctors from the UK and Germany presented studies showing that the drug is an effective long-term treatment in HIV/hepatitis B coinfected people. 

Like HIV, hepatitis B can develop resistance to the drugs used to treat it. The UK doctors found that tenofovir often worked in people who had hepatitis B that was resistant to 3TC, and none of the patients in the German study developed resistance to tenofovir.

Hepatitis C

Hepatitis C also affects the liver. It can be caught by contact with hepatitis C infected blood, and there have been reports of sexual transmission amongst gay men, most of whom have been HIV-positive.

Treatment is available for hepatitis C. It is most successful when provided soon after a person contracts the infection. Much lower rates of treatment success are seen in HIV-positive people who have had hepatitis C for a long time.

Doctors have been looking at ways to improve the chances of treatment for long-term, or chronic, hepatitis C working.  Unlike anti-HIV therapy, treatment for hepatitis C treatment isn’t life-long. The duration of treatment varies according to the strain, or genotype, of hepatitis C a person is infected with. Genotypes 2 and 3 are considered easier-to-treat, and people with these strains of hepatitis C normally receive 24-weeks of treatment. The harder-to-treat hepatitis C genotypes are 1 and 4, and they are normally treated for 48 weeks.

Doctors have suggested that providing HIV/hepatitis C coinfected people with an extra six months of treatment could improve the chances of treatment success. But a study presented to the Paris workshop found that only people infected with the genotypes 2 and 3 benefited from prolonged treatment.

Another study presented in Paris found that giving people with HIV/hepatitis C a second course of anti-hepatitis C therapy if their first was unsuccessful, rarely worked. The patients in this study had previously received interferon-based treatment for hepatitis C. It is now recommended that people should receive pegylated-interferon in combination with ribavirin. But of the 21 people in the study, only four had a sustained response to their hepatitis C treatment. 

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copy of copy of copy of 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.uk or phone 020 7840 0050.