Treatment and infectiousness - Swiss statement generates debate at Mexico conference

As expected, what has come to be known as the “Swiss statement” on the infectiousness of HIV-positive people with an undetectable viral load has proved controversial at this year’s International AIDS Conference.

In January, senior HIV doctors and researchers in Switzerland issued a statement that people taking HIV treatment with an undetectable viral load in their blood for at least six months were not infectious to their sexual partners, provided they took their treatment properly and did not have a sexually transmitted infection (STI).

The statement was debated in a heated two-hour meeting at a satellite event, prior to the conference.

One of the authors of the statement said that it was never intended for worldwide publication. Rather it was meant to be used by Swiss doctors to help them discuss sexual risk-taking with their patients who had steady partners.

He also stressed that they did not intend it to mean that an undetectable viral load was a replacement for condoms.

But he defended the statement, noting that sex with condoms was not 100% safe, rather carrying a risk that was “in a comfortable range that people can live a normal life. We would place sex under antiretroviral therapy in a similarly safe range, but we only consider this ‘safe’ under special conditions.”

Concern was expressed by others at the meeting. For example, one doctor said that the assumption that transmission was not possible if viral load was below a certain level was more of a belief than a fact.  Nevertheless, he also noted that some anti-HIV drugs are very good at getting into sexual fluids and may be acting as a de facto microbicide.

A delegate from UNAIDS said that the Swiss statement was irrelevant for most people with HIV around the world, pointing out that there was limited access to viral load testing and high rates of STIs in many of the countries hardest hit by HIV.

The statement was supported by some community activists, who noted that it helped reduce stigma and discrimination.

Microfinance schemes reduce HIV risk for women in South Africa

Microfinance – focused on the economic empowerment of poor women – reduces HIV risk behaviour and partner violence, a study has shown.

The study was conducted in South Africa and involved very poor women. They were given small loans to start businesses such as buying and selling local produce, selling new and used clothes, providing child care or running food stalls. Almost all the loans were fully repaid.

Not only did the scheme help to improve economic well-being, but the researchers also found that it reduced unprotected sex with casual partners and reduced partner violence.

The study is now going to be expanded and it is expected to reach 15,000 households in the Limpopo province between 2008 and 2010.

Treatment changes and lipodystrophy

Some anti-HIV drugs can cause body fat changes including fat loss from the face, limbs and buttocks, or fat gain around the internal organs in the belly or fat gain between the shoulders. This collection of side-effects is often called lipodystrophy.

Two drugs in particular – the NRTIs d4T and AZT – have been associated with fat loss, and neither drug is now recommended for routine use in some countries, including the UK. However, they are still important treatment choices in many developing countries.

UK research focused on protease inhibitors has found that switching to the protease inhibitor atazanavir (Reyataz) boosted by ritonavir does not reduce central fat gain. The researchers used scans to look at levels of fat in the patients who changed to atazanavir and those who remained on Kaletra  (lopinavir/ritonavir). There was no difference in levels of fat around the belly after a year.

Atazanavir is less likely to cause increases in blood fats than other protease inhibitors, and it had been hoped that switching to the drug would also have a positive effect on body shape. Exercise and diet seem to be the only ways to treat visceral fat, which the study’s researcher described as “a very important challenge.”

He also suggested that treatment with protease inhibitors might not be the cause of visceral fat accumulation at all.

A separate study looked at the effects on limb fat of switching from AZT/3TC (Combivir) to tenofovir/FTC (Truvada). Half the patients in the study stayed on Combivir, while the others switched to Truvada. Changes in limb fat were checked after six months using scans.

Overall there was a slight, but not significant, gain in limb fat in the patients who switched to Truvada, and the patients who stayed on Combivir continued to lose fat. But switching to Truvada did seem to have more benefit for patients with more severe fat loss.

It is possible that the study did not last long enough. Some other research has shown that it can take up to two years after changing treatment for real improvements to be seen.

High HIV incidence amongst men who have sex with men in Thailand

Research in Thailand has found that 5% of gay and other men who have sex with men are infected with HIV each year.

The risk factors for becoming infected with HIV include age over 30, lower level of education, receptive anal sex without a condom, and use of recreational drugs, including poppers. Recent research from the UK has also found a connection between the use of poppers and an increased risk of infection with HIV.

Thailand has had some success at controlling the spread of HIV, but their prevention efforts have been focused on sex workers and injecting drug users. A meeting on the opening day of the conference heard that the HIV-prevention needs of gay and other men who have sex with men was often overlooked, and it is expected that the conference will help focus attention on the neglected HIV epidemic amongst gay men in many parts of the world

Lipodystrophy in Thailand

HIV treatment in resource-limited countries relies on d4T and AZT – the drugs most associated with body fat changes.

In Thailand, standard first-line HIV treatment is GPOVir, a fixed-dose combination pill of d4T, 3TC and nevirapine.

Researchers found that three years after starting this combination, 18% of patients switched to a combination that included AZT because of lipodystrophy.

But lipodystrophy did not seem to result in patients having poorer adherence to their treatment.

Because of the risk of lipodystrophy, the World Health Organization recommended that d4T dosing levels should be reduced. Despite this recommendation, patients in this study were still taking full-dose d4T.

HIV treatment and TB

Tuberculosis (TB) is the biggest single cause of illness and death amongst people with HIV worldwide.

There has been a great deal of debate about the right time to start HIV treatment for people with a low CD4 cell count who are receiving TB treatment. This is because anti-HIV and anti-TB drugs can interact, and because of a risk of what is called immune reconstitution inflammatory syndrome.

Two studies presented to the Mexico conference have provided conflicting results about the benefits of early HIV treatment for patients with TB.

The first study in Iran showed that patients who took early HIV treatment were less likely to die than those who delayed taking anti-HIV drugs.

But a separate study in Argentina found a higher rate of death amongst patients who took early HIV treatment.

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