Prompt HIV treatment is especially important for some people

As we have reported several times over the past year, there is now conclusive evidence that it is better to start HIV treatment sooner, rather than later. This applies to all people living with HIV.

This was proven in a large study, called START, whose main findings were reported last summer. Everyone who took part had a high CD4 cell count, above 500, when they entered the study.

START showed that by beginning HIV treatment early people living with HIV can significantly reduce their risk of developing AIDS, other serious illnesses unrelated to AIDS, or dying. 

The benefit was seen in men and women, in people of all ages, in all regions of the world, and in people with different medical histories. In all subgroups, people with HIV who began treatment immediately did better than people who waited.

Nonetheless, a new analysis from the study has shown that there were some subgroups in which the benefit was especially pronounced. They found that starting treatment without delay is especially important for:

  • People over the age of 50.
  • People with a very high viral load, above 50,000 copies/ml.
  • People with a low CD4/CD8 ratio.
  • People who have a high risk of developing heart disease.

Prompt treatment was especially likely to prevent illnesses in individuals in these groups.

These findings could be important if you have chosen not to start HIV treatment for the moment. They could help you and your doctor assess how safe it is to continue without treatment. 

The CD4/CD8 ratio is probably not familiar to many readers. CD4 cells and CD8 cells are two different types of cells in the immune system. The ratio is an indication of how balanced your immune function is.

HIV-negative people typically have a ratio of 1 (meaning that there are as many CD8 cells as CD4 cells) or above.

People living with HIV may have a lower ratio. A ratio of 0.5 shows that there are half the number of CD4 cells as CD8 cells. In this study, people with ratios below this level were more likely to get ill if they did not take HIV treatment. Their results improved when they began HIV treatment.

The researchers found that CD4/CD8 ratios gave more useful information than CD4 counts on their own.

Efavirenz and suicide

Another analysis from the START study has shed more light on whether the drug efavirenz raises the risk of suicidal thoughts and attempted suicide.

Efavirenz is a very widely used drug, included in the tablets Atripla and Sustiva, but it gives some people unpleasant side-effects, affecting their thoughts and feelings. Most commonly, these include dizziness, intense dreams and problems sleeping. Smaller numbers of people have had more serious problems, such as delusional thoughts and suicidal thoughts.

These side-effects are more likely to happen to people who’ve previously suffered from depression or other mental health issues. Doctors are advised not to prescribe efavirenz to patients who have previously had these kinds of problems.

The new analysis confirmed that many doctors do avoid giving efavirenz in these situations. Most people who’d previously needed treatment for depression, bipolar disorder, psychosis or drug dependency were given other anti-HIV drugs.

But some people with these issues were in fact prescribed efavirenz. And among people prescribed efavirenz, rates of suicidal thoughts and suicidal behaviour were slightly higher in people who began their HIV treatment immediately than in people who were asked to delay it.

It’s important to emphasise that the numbers here are very small and the difference is slight. Each year, 3 in 1000 people who began treatment immediately had suicidal behaviour. This compares with 2 in 1000 people who delayed treatment. Most cases were of suicidal thoughts, rather than actual suicide attempts.

People with previous mental health issues were much more likely to have suicidal behaviour than other people taking efavirenz.

The study shows the importance of doctors finding out about people’s mental health before prescribing efavirenz-based treatments (including the single-tablet treatment Atripla).

If you’ve suffered from depression or other problems in the past but have been given this drug, it would be a good idea to discuss this with your doctor. You could consider switching to another drug.

There is a lot of mental health support available to people with HIV. So if you’re low or depressed for any reason it makes good sense to speak to your doctor or another member of your healthcare team. For more information, you may find our booklet ‘HIV, mental health & emotional wellbeing’ helpful.

Young people moving into adult HIV care

A small study from the Netherlands shows that adolescents living with HIV are especially likely to have problems with their HIV treatment when they move from paediatric to adult HIV services (typically around the age of 18). Several had problems adhering to their medication, stopped having an undetectable viral load or missed appointments.

Problems were more common for young people who had limited education, poor knowledge of HIV or who needed guidance from others in order to adhere to their medication.

While adolescents are still attending paediatric services, parents, caregivers and clinicians need to help them develop independence and take responsibility for their own health, the researchers say. Gradually preparing a young person for the transition from paediatric to adult HIV services is important.

You can find out more about helping your child with this process in NAM’s booklet ‘HIV & children’.