HIV update - 26th November 2014

HPV vaccine recommended for gay men

Adult gay men should be offered vaccination for human papillomavirus (HPV), the UK’s expert vaccine committee has recommended.

Certain strains of HPV can cause anal cancer, cervical cancer, genital warts and anal warts. Since 2008, HPV vaccination has been recommended for adolescent girls in the UK.

But rates of anal cancer and warts are considerably higher in gay men – especially gay men living with HIV – than in other men. Whereas heterosexual men are likely to benefit from lower rates of infection in their female sexual partners, this would not apply to gay men if the policy remained to vaccinate girls only.

The Joint Committee on Vaccination and Immunisation (JCVI) has recommended that all men who have sex with men aged 16-40 years attending sexual health or HIV clinics should be offered the version of the HPV vaccine which protects against both anal cancer and warts.

Of note, they have not recommended that all adolescent boys are offered the vaccine – this would provide more comprehensive protection but would be more expensive. Some campaigners believe the recommendation does not go far enough.

There’s still a chance that the recommendation won’t be implemented by the NHS. Terrence Higgins Trust has invited supporters to ask their MPs to call on health ministers to provide the HPV vaccination to men who have sex with men.

New treatments for hepatitis C

There’s more good news on treatment for hepatitis C. In several trials of new hepatitis C drugs involving people with hepatitis C and HIV co-infection, over 90% of HIV-positive people had no traces of hepatitis C after 12 weeks of treatment. The drug regimens are made up of tablets only, often with more than one drug combined into a single tablet, and no injections of interferon are needed.

Until recently, it was thought that recommendations for treating people who have HIV and hepatitis C co-infection had to be different from those for people with hepatitis C mono-infection. This was because people with HIV co-infection tended to have a poorer response to hepatitis C treatment and separate clinical trials were needed.

But we now know that when a potent combination of two or three new hepatitis C drugs is taken, people with HIV co-infection can have results that are comparable to people who only have hepatitis C.

In the following studies, people were generally already doing well on HIV treatment, with undetectable viral loads and good CD4 counts. But most had hepatitis C genotype 1a, which until now has been considered ‘hard to treat’. And most had an inherited gene which meant that they would probably not do well on hepatitis treatment that includes interferon injections.

The first study tested two new drugs, sofosbuvir and ledipasvir, which are combined in a single tablet called Harvoni. The tablet was approved by European regulators last week. Researchers gave the treatment to 50 HIV-positive people, none of whom had taken hepatitis C treatment before. Most had a high hepatitis C viral load and a quarter had advanced liver fibrosis (but none had cirrhosis, the more serious scarring of the liver). After 12 weeks of treatment, all but one of the patients were cured of hepatitis C.

A rival drug company is offering a regimen which includes three new drugs. This regimen involves a tablet called Viekirax (which combines two new drugs, ombitasvir and paritaprevir, as well as a ritonavir booster), another new drug dasabuvir (Exviera), and the option to take these alongside the existing drug ribavirin. European regulators have given preliminary support to this combination, with a final decision expected next year.

To test this regimen, another small study recruited HIV-positive people who were mostly taking hepatitis treatment for the first time. One in five had liver cirrhosis. Whether people took the drugs for 12 or 24 weeks, over 90% had no traces of hepatitis C after the treatment was finished. A larger trial will confirm which length of treatment is best.

And another study tested the so-far unlicensed combination of two new drugs, grazoprevir and elbasvir. Treatment for people living with HIV was most successful when the combination was taken along with ribavirin – in 97% of people, hepatitis C could not be detected.

In all these studies, side-effects were not a major problem.

Finally, a study showed good outcomes for people living with HIV who had liver transplants. The transplants were all done because the person had hepatocellular carcinoma (HCC, a type of liver cancer that may occur when a person has cirrhosis). People who had a transplant did better than people who had their liver cancer treated in another way. Outcomes after a transplant were as good for people living with HIV as for people who didn’t have HIV.

HIV vaccine news

Some encouraging news about the development of HIV vaccines was reported at a recent conference. The vaccine being studied stimulates a strong, broad immune reaction to the virus. Specifically, it stimulates the CD8 branch of the immune system to quickly kill cells that are infected with a virus. It does not directly target the virus itself.

The research has only been done in monkeys so far.

It shows that in 60% of the monkeys given the vaccine, subsequent infection with SIV (the monkey equivalent of HIV) failed to take hold. At first, there were tiny traces of the virus in some cells, but there was so little virus that these monkeys’ viral load remained undetectable. Three years later, almost all of these monkeys had no sign of infection whatsoever, and two who did were able to control the virus without treatment.

So the vaccine prevents monkeys acquiring the virus.

But it’s also hoped that it could help to control the virus in cases of long-term infection. In other words, that a future vaccine could have a benefit for people already living with HIV.

An ongoing experiment is giving the vaccine to animals that have had SIV for a few years and have been taking antiretroviral drugs. Soon after taking the vaccine, treatment with antiretroviral drugs is stopped. The scientists do not think that the vaccine will clear the viral infection entirely, but they are hopeful that it will keep it under control for some time, making a prolonged break from drug treatment possible.

If all this works, human trials could begin in 2016.

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