- Anti-HIV treatment and the immune system: Studies don’t agree about the ability of anti-HIV treatment to restore the immune system’s ability to fight tuberculosis.
- Tuberculosis: Anti-HIV and anti-tuberculosis drugs can be used together without reducing the effectiveness of either treatment.
- Anti-HIV treatment: Using a resistance test to choose the most effective drugs can mean that people who were infected with drug-resistant HIV do just as well on their first HIV treatment combination as people who had fully drug-sensitive virus.
- Sexual health: Guidelines have been published for the treatment of sexually transmitted infections in people with HIV.
- HIV and hepatitis: HIV-positive people with hepatitis B can have successful liver transplants.
- Terrence Higgins Trust cuts: Largest UK HIV charity closes its specialist welfare/immigration/housing advice service.
- Pharmacology workshop: Researchers look at the advanced science of individual responses to HIV treatment.
Anti-HIV treatment and the immune system
Potent anti-HIV treatment has dramatically cut the amount of illness and death caused by HIV in countries like the UK. It does this by lowering the amount of HIV in the blood – viral load – allowing the body’s natural defences against infection – the immune system – to strengthen. Doctors usually assess the strength of the immune system by looking at the number of CD4 cell count a person has.
CD4 cells aren’t the only cells in the immune system and HIV can also damage the ability of these cells to respond to infections. There’s been a lot of debate concerning the extent to which HIV treatment restores the immune system’s ability to respond to infections, and some researchers believe that, even with successful anti-HIV treatment, some people with HIV will still be more vulnerable to certain infections than HIV-negative people.
Two recent studies examined this issue. They looked at the restoration of a tuberculosis (TB)-specific immune system response in people taking anti-HIV treatment. TB is the most common AIDS-defining illness worldwide and unlike most other infections and cancers used to diagnose AIDS, it can develop in HIV-positive people with relatively high CD4 cell counts.
The first study was conducted in South Africa and involved a small number of children. All had very weak immune systems and high viral loads when they started anti-HIV treatment. As expected, anti-HIV treatment boosted the immune system and led to a dramatic reduction in viral load. In the laboratory, researchers examined the ability of a TB-like germ to grow in blood taken from the children. They found that after only three months of HIV treatment the ability of the TB-like germ to grow was significantly reduced.
However, a second small study produced conflicting results. This study involved HIV-positive people who had been taking anti-HIV treatment for over a year and were doing well – all had an undetectable viral load and a CD4 cell count above 300. They compared the number of TB-specific immune system cells in these people to people who had only just been infected with HIV and people with TB who were HIV-negative. They found that the people who’d had HIV for a long time had a poorer TB-specific immune response than either of the other groups of patients, even though they were being successfully treated with anti-HIV drugs.
Tuberculosis
Tuberculosis (TB) is the main cause of illness and death in people with HIV around the world and approximately 200 cases of TB are diagnosed in HIV-positive people in the UK every year.
Many people who develop TB have such weak immune systems and low CD4 cell counts that they need anti-HIV treatment as well as treatment for their TB. However, care is needed when using anti-HIV and anti-TB drugs together. This is mainly to avoid a very unpleasant inflammatory response which can occur if anti-TB and anti-HIV drugs are used together. British HIV doctors have made recommendations about the best way to treat HIV and TB together. It is generally recommended that anti-HIV treatment shouldn’t be started until TB treatment has been completed if you have a CD4 cell count above 200. If you have a CD4 cell count between 200 – 100, then you’re recommended to wait until you’ve taken two months of anti-TB treatment before you start anti-HIV drugs. If you’re CD4 cell count is below 100, then you should start anti-HIV drugs as soon as possible after starting TB treatment.
There are also other concerns about using anti-TB and anti-HIV drugs at the same time. It’s known that some drugs can interact, meaning that there’s less of some drugs available to fight either infection, or larger amounts of other drugs increasing the risk of side-effects. What’s more, anti-TB drugs, like anti-HIV drugs, need to be taken properly to work, and some people find it difficult to take so many pills properly and adhere to their treatment schedules.
Doctors in London wanted to see if treating HIV and TB at the same time meant that people had a poorer response to anti-HIV and anti-TB treatment. To do this, they compared the CD4 cell count and viral load of over 150 HIV-positive people who also received TB treatment to that of HIV-positive people who didn’t have TB and who just received HIV treatment. They also compared the response to TB treatment in the HIV-positive people to that of HIV-negative TB patients.
After six months of HIV treatment, the HIV/TB patients had just as good a fall in viral load and increase in CD4 cell count as the people who were only treated for HIV. The doctors also noticed that HIV/TB patients were no more likely to experience a relapse in TB as people who only had TB.
They conclude that HIV and TB can be successfully treated together.
HIV treatment
HIV can develop resistance to drugs used to treat it. This can mean that anti-HIV treatment doesn’t work as well and that a person has fewer anti-HIV drugs from which to choose. Resistance often develops because a person doesn’t have proper adherence to their anti-HIV treatment.
It is possible to become infected with a drug resistant strain of HIV. This is happening with increasing frequency as the number of people taking anti-HIV treatment increases – and it’s currently estimated that about 10% of people newly infected with HIV in the UK have drug-resistant HIV before they’ve taken a single anti-HIV drug.
In the UK and other countries, guidelines have been developed to help doctors select the most effective HIV treatment, that is the easiest to take and causes fewest side-effects. You can read of a summary of the UK HIV treatment guidelines in NAM’s HIV Therapy booklet.
If you were infected with drug-resistant virus, then the recommended HIV treatment might not work for you. Therefore, doctors in the UK recommend that everybody should have a resistance test to look for drug-resistant HIV before they start HIV treatment.
The value of doing this has been shown by doctors in Germany. They found that people who were infected with drug-resistant HIV who had a resistance test before starting their first combination of anti-HIV drugs did just as well as people who had HIV with no resistance. People with resistance were just as likely as those without to experience a fall in their viral load to undetectable levels, and increases in CD4 cell count were comparable between the two groups of people.
Within the last week, US HIV treatment guidelines were updated to recommend that everybody should have a resistance test before starting HIV treatment.
Sexual health
Good sexual health is important to everybody, who is especially so to people with HIV. Certain sexually transmitted infections can cause serious illness in HIV-positive people and untreated sexually transmitted infections can increase the chance of HIV transmission.
Guidelines have been prepared by the British Association for Sexual Health and HIV (BASHH) for the treatment of sexually transmitted infections in people with HIV. They also look at the current issues surrounding the criminalisation of the sexual transmission of HIV.
In recent years, syphilis has re-emerged in the UK and many other countries, the infection disproportionately affecting HIV-positive gay men. The sexually transmitted infection lymphogranuloma venereum (LGV), a form of chlamydia, has also re-emerged in recent years, and once again, the infection has mainly affected HIV-positive gay men.
The new guidelines recommend the same treatment for HIV-positive as HIV-negative people for most sexually transmitted infections. More intensive treatment for syphilis and herpes is recommended, particularly if a person with HIV has a weak immune system.
Some strains of the virus that causes genital warts can increase the risk of cervical and anal cancer, and both of these cancers occur with greater frequency in HIV-positive people. The guidelines recommend anal Pap smears for HIV-positive women. However, they do not recommend anal pap smears for HIV-positive gay men - there is not yet the evidence to show that this is of any real value.
HIV and hepatitis
Thanks to effective anti-HIV treatment, the amount of illness and deaths caused by HIV in countries like the UK has fallen dramatically. But people with HIV still do become unwell, and one of the main causes of illness and death in people with HIV is infection with hepatitis B virus or hepatitis C virus. These infections can be transmitted in similar ways to HIV and affect the liver. In the long-term they can cause irreversible damage to the liver, including liver cancer and even death. For some people with hepatitis B or hepatitis C a liver transplant offers their best hope of longer-term survival.
People who are doing well on HIV treatment with advanced liver disease are now considered to be good candidates for liver transplant, and a new American study has shown that HIV-positive people who need a liver transplant because they have hepatitis B can do very well, even if they have resistance to a key drug used to treat both HIV and hepatitis B.
The study involved four people with HIV and hepatitis B. They had a CD4 cell count of approximately 275 when they had their liver transplant. All had large amounts of hepatitis B in their blood and three were resistant to 3TC (lamivudine, Epivir/Zeffix) a drug that is active against both HIV and hepatitis B. All four people survived, none rejected their new livers and all had undetectable amounts of hepatitis B in their blood 18 months to four years after their liver transplant.
However, the doctors noted that many other patients were referred too late to be good candidates for liver transplant and died or were no longer good transplant candidates before a liver became available.
A hepatitis B vaccine is available and everybody who is HIV-positive should receive it and have their level of hepatitis B immunity checked at regular intervals.
Terrence Higgins Trust cuts advice service
The UK’s largest HIV charity, the Terrence Higgins Trust (THT) has closed its specialist advice centre. This means it will no longer be providing advanced casework support and appeals and tribunals work. Advice at this level was provided by solicitors and THT will be referring new cases needing this level of support to lawyers with specialists in these areas.
The charity will continue to provide lower level advice on issues such as welfare benefits, immigration issues and housing, principally through its telephone service THT Direct and its regional offices.