Risk factors under patient control associated with increased risk of death

A large study looking at the safety of HIV treatment has found that risk factors that are at least partially under the control of individuals increased the likelihood of study participants dying.

Since 1999, the D:A:D study has been collecting information on the safety of HIV treatment, and illness and death amongst the study participants. Over 33,000 patients have been studied and together they’ve contributed almost 160,000 person-years for analysis.

Almost 2200 deaths have been recorded since the study began. The researchers have found that the annual death rate has fallen from 1.6% at the start of the study to 1% now.

HIV-related illness remained the most common cause of death (32%), followed by liver disease (14%), non-HIV-related cancers (12%), and cardiovascular disease (11%).

Some factors that can’t be changed were associated with an increased risk of death – age and sex.

But the researchers also found some factors that could possibly be changed also increased the likelihood of study participants dying. These included being underweight, smoking, or having diabetes, high blood pressure, or infection with hepatitis C.

A low CD4 cell count and a high viral load were also identified as risk factors.

HIV and hepatitis C co-infection

Longer course of treatment can have benefits

Longer duration of hepatitis C treatment can mean that over 50% of co-infected individuals who’ve had an early response to hepatitis C treatment clear the infection.

The study involved over 300 HIV/hepatitis C co-infected patients. They received hepatitis C treatment consisting of pegylated interferon and weight-based doses of ribavirin.

Response to treatment was assessed after twelve weeks. Those who were assessed to have had an early treatment response (a two log₁₀ fall in hepatitis C viral load or a undetectable hepatitis C viral load) continued with their hepatitis C therapy for 72 weeks. That’s longer than the standard 48 weeks of treatment usually given to people with HIV/hepatitis C co-infection.

A total of 56% of patients had an early treatment response, and 51% of these individuals went on to have a sustained response to treatment – an undetectable hepatitis C viral load six months after the completion of therapy.

People with the easier-to-treat hepatitis C genotypes (2 and 3) were more likely to clear infection with hepatitis C, as were those who had an undetectable hepatitis C viral load after twelve weeks of treatment.

But many people found it difficult to cope with treatment side-effects. Over a third (35%) stopped treatment before the 72 weeks were over, with fatigue and poor quality of life being the main reasons.

More hospitalisation and disability

A lot of research, including the D:A:D study referred to above, has shown that liver disease caused by hepatitis B or hepatitis C is an increasingly important cause of illness and death amongst people with HIV.

Now American researchers have found that HIV/hepatitis C co-infected patients spend more time in hospital, need more emergency care, and have more time off work due to sickness than people only infected with HIV.

The research involved over 3000 HIV-positive patients and 359 (12%) were co-infected with hepatitis C.

Regardless of CD4 cell count, co-infected patients spent more time as hospital inpatients than individuals only infected with HIV.

Furthermore, the researchers also found that at all CD4 cell count levels, co-infected patients visited hospital emergency departments more and had more days disability (defined as days spent in bed, or forced to cut back on work or other activities).

The researchers concluded that co-infected patients “have significantly increased rates of healthcare utilization and disability days, generating substantial additional burdens on the system of care for HIV-infected patients”.

HIV and TB treatment – corticosteroid improves outcome in those developing IRIS

Taking HIV treatment and treatment for tuberculosis (TB) at the same time can cause what’s known as an immune reconstitution inflammatory syndrome (IRIS) to develop. This can involve unpleasant symptoms and can, in some cases, be dangerous.

A study has found that outcomes are improved in patients with IRIS if they receive treatment with the corticosteroid prednisone.

A total of 110 patients with IRIS were included in the study, which was conducted in Cape Town. They were randomised to receive prednisone or a placebo.

Patients who received prednisone spent less time in hospital. The prednisone-treated patients also needed fewer medical procedures for their IRIS. Significant improvement in the symptoms of IRIS were also observed in the patients who took prednisone.

Treatment with the corticosteroid was not associated with an increased risk of side-effects or flare-ups of other infections.

“We would advocate the use of prednisone to treat patients with TB-IRIS,” the researchers told the conference.

Antiretroviral use by mothers with low CD4 count reduces risk of transmission during breastfeeding

HIV-positive breastfeeding mothers who have a low CD4 cell count are much less likely to pass on the virus to their babies if they take antiretroviral therapy.

The research involved over 2300 infants who were HIV-negative 14 weeks after birth. They were monitored until they reached 24 months of age.

A total of 130 infants (6%) were infected with HIV in this period. The rate of mother-to-child transmission was highest (11 per 100 person-years) amongst infants whose mothers had a CD4 cell count below 250 cells/mm³ but who weren’t taking HIV treatment. But it was only 2 per 100 person-years if a mother with a CD4 cell count below 250 cells/mm³ was taking HIV treatment. This was an 82% reduction in risk.

HIV testing and counselling – study finds benefits from home-based approach

Home-based HIV counselling and testing can increase the acceptability and uptake of HIV testing, two studies conducted in Uganda have shown.

The first study found that household members of people receiving home-based antiretroviral treatment were more likely to test for HIV than the household members of individuals who received clinic-based HIV care.

The second study looked at door-to-door voluntary HIV testing and counselling. The researchers found that this approach not only improved rates of HIV testing but also reduced HIV-related stigma. However, it didn’t affect levels of sexual risk behaviour.