Treatment Breaks Long Payback

posted: 19/01/2011

Eight years after some people with HIV took a break from taking their anti-HIV treatment, their treatment break continues to have a harmful effect. People having treatment breaks see smaller rises in their CD4 cell count, more HIV-related illness, and tend to die earlier. This new Swiss research also shows that the longer the break from treatment was, the more harm is done to health.

Taking treatment breaks is definitely not recommended now, but it was a choice some people made, for example because of side effects (which were far worse in the early days of HIV treatments).

Don’t Stop the Treatment
“The results strongly support the concept that patients should be discouraged to discontinue antiretroviral therapy,” comment the investigators. If they wrote this in plain English they would simply say 'Don't stop HIV treatments; keep taking the tablets.'

People taking antiretroviral drugs may stop taking HIV treatments. We already knew from the SMART study some years ago that you could still see harmful effects of stopping treatment around two years later. This latest Swiss study looked at what happens after this. Is the harm permanent when people stop taking HIV treatments?

They looked at almost 2500 people who started HIV treatment between 1996 and 2008. They split the people into three groups depending on their use of treatment, so any differences because of treatment would be clear to see.

More than half the people (51%) stopped their HIV treatment at least once. Around one fifth (19%) didn’t stop taking their HIV treatment but sometimes had a viral load above 1000. The third group were people who kept taking HIV treatments and always had a viral load below 1000. Normally, with HIV treatment, viral load should become undetectable, almost 0.

CD4 Counts Up, or Down?
Average CD4 count rose (which is good) from 210 to 491 cells after eight years. However, the size of any rise varies with the group. Almost two thirds of the people who stopped taking HIV treatments did not see their CD4 count rise above 350. People who carried on taking treatments were rather more likely to see CD4 counts rise above 350 (87% had a CD4 of 350 or more among those taking treatments all the time, compared with 63%, among the people who stopped taking HIV treatments).

Those who stopped HIV treatment were significantly less likely to see their CD4 count rise higher still, to above 500.

Longer treatment breaks are worst
The longer you stopped treatment, the less your CD4 count rose. Average CD4 counts actually fell among people who stopped treatment for two and a half years.

Smaller rises in CD4 counts are also seen among older people, people who also have hepatitis C, and people starting HIV treatments late.

More HIV-illnesses and AIDS conditions
Taking treatment breaks means people are more likely to have HIV-related illnesses such as oral hairy leukoplakia, oral thrush, and herpes. People are more likely to develop an AIDS-defining illness.

The longer you stopped taking treatment, the more likely you are to get an AIDS-defining illness. Even stopping treatment for just one month raises this chance, and it doubles when the break in treatment lasts 6 months, and is roughly half as large again if the break is over two years. “If any interruption is required, it should be as short as possible to avoid poor clinical outcomes,” comment the investigators.

Deaths too
Death rates are higher among people stopping HIV treatment (20 per 1000 person years) and lower among people who keep taking the tablets. 4 deaths per 1000 person years occur among those stopping HIV treatment and the death rate is just half this among people who keep taking treatments with an undetectable viral load.

The earlier SMART study (which looked back at people two years after they had stopped HIV treatment) found more deaths from cardiovascular disease, but this longer-term Swiss study didn’t find this. “The absolute risk of cardiovascular events remained low,” the researchers say.

The investigators believe their study “adds important new information on the long-term clinical consequences of treatment interruptions and the effect of duration of treatment interruptions.”

They write that their findings show “an interruption of ART for 6 months or more resulted in sub-optimal recovery of CD4 T lymphocytes and increased risk of opportunistic complications or death.”

Best – Treat Early, Don’t Stop, Get Undetectable Quick
To achieve the best outcomes in patients the authors suggest “it appears to be essential to initiate ART early, avoid treatment interruptions and suppress plasma HIV-1 RNA to values as low as possible."

People having problems with taking treatment should seek help from the HIV clinic or HIV community organisation. In NW England people are welcome to contact our services team.

Source with reference

'Remarkable' Improvements - UK HIV Patients

posted: 02/08/2010

People taking HIV treatments were broadly doing much better between 2000-2007, and things will continue to improve until at least 2012, says a report in HIV Medicine. The researchers say that the improvements seen between 2000 and 2007 are “remarkable”.
 

Since 2000 death rates have continued to fall in real terms, and the number of people with a low CD4 cell count (below 200) has also halved and there has been a big rise in the proportion of people with an undetectable viral load. Although the proportion of people with triple-class treatment failure has risen, nonetheless over half the people with triple HIV drug class treatment failure still had an undetectable viral load.
 

Five out of six people on HIV treatment have undetectable viral load
“The success of ART [antiretroviral therapy] has improved markedly over the period 2000-2007, with five in every six ART-treated patients having a viral load below 50 copies/ml. Nine in 10 of all patients now have a CD4 count above the particularly high risk level of 200 cells/mm3”, comment the investigators.
 

Watching for improvements
The study was a reality check, to see if the key outcomes for HIV-positive people using HIV clinics in the UK were being maintained, or even improved. They checked four key markers of the success of HIV treatments between 2000-2007: deaths, low CD4 cell count, multi-class drug resistance, and detectable viral load. They also designed a computer model to project how these things may change, for better or worse, between 2007 and 2012.
 

To do the study they used data in the UK Collaborative HIV Cohort (UK-CHIC), as well as the Health Protection Agency’s Survey of Prevalent HIV Infections Diagnosed (SOPHID) study. The number of people in the UK-CHIC rose by over 50%, from 9041 in 2000 to 14,812 in 2007.
 

By 2012 there will be 74,000 people using HIV clinics in UK
When these were combined with data from the HPA, it is now expected that the total number of patients receiving HIV care in the UK will increase to 74,000 by 2012, of whom 73% would be taking treatments.
 

Different types of HIV drugs
By 2007, 81% of people having treatment have taken an NNRTI, 56% a protease inhibitor, and 39% had experience of all three of the original classes of anti-HIV drugs.
 

Doing better - Fewer people have low CD4 counts, and more have undetectable viral load
There was a substantial fall in the proportion of people with a CD4 cell count below 200 (19% in 2000, 8% in 2007). A CD4 below 200 makes opportunistic HIV illnesses more likely. The fall in low CD4 counts was matched by a rise in the percentage of people on treatment who have an undetectable viral load - undetectable means below 50 (62% in 2000, 83% in 2007). An undetectable viral load means the treatment is working well at keeping HIV under control, and means people are much less likely to pass on HIV.
 

Deaths stable
The observed annual number of deaths amongst people with HIV remained stable between 2000-2007, and the computer model suggested that there would be no substantial increase through to 2012. Death rates plummeted after effective combination treatments began in the mid 1990s. The investigators comment, “there is no apparent increasing trend in the numbers of deaths, despite the increasing number of people infected with HIV, indicating a decrease in the death rate.”
 

More have used the three main HIV drug types
The number and proportion of people who have now taken the three main classes of HIV drugs has risen from 14% in 2000 to 19% in 2007. Based on data from the UK-CHIC, they estimate that the proportion of patients with extensive triple class treatment failure increased from 1% in 2000 to 4% in 2007.
 

However, better HIV treatment and new drugs are more than keeping pace with this. The proportion of people who had extensive treatment failure leading to a detectable viral load fell from 80% in 2000 to 48% in 2007.
“This decrease is projected to continue as more patients start newer drugs, including those from the newly available classes such as integrase inhibitors and perhaps CCR5 antagonists”, write the researchers.
 

Less transmission of drug-resistant HIV
Such a fall in the number of treatment-experienced patients with a detectable viral load is likely to have public health benefits. The investigators comment, “our results have positive implications for future transmission of resistant virus, with the proportion of new infections with resistant virus predicted to remain low.”
 

Outlook brighter even for people with extensive treatment experience
The researchers believe that the improvements in outcomes between 2000 and 2007 are “remarkable”.

They conclude that newly licensed drugs and future developments in HIV treatment and care will mean that further improvements in outcomes are likely for people who have been extensively treated.
 

Source

Reference : Bansi L et al. Trends over calendar time in antiretroviral treatment success and failure in HIV clinic populations. HIV Medicine 11: 432-38, 2010.

First Viral Load Predicts

posted: 10/06/2010

The first viral load is a good predictor of how HIV may develop in each person, British researchers have found. That makes regular check-ups at a specialist HIV clinic important, especially if the person’s first viral load was above 10,000.
 

At each HIV clinic visit people have blood tests. Two of the most important are those which monitor the CD4 cell count and Viral Load .

The CD4 cell count gives a rough picture of the health of the immune system. The higher it is, the healthier the immune system.
 

Viral load measures how much HIV is circulating in the blood. Low Viral Loads are best – ideally when they can’t find any HIV in the bloodstream, because it is ‘undetectable’.
 

New UK research from London’s Royal Free Hospital has underlined that it is important to check both CD4 count and Viral Load regularly. Usually HIV clinics do this 3 or 4 times a year, sometimes more often.
 

Close relationship between Viral Load and CD4

The new study shows that there is a very close relationship between the viral load going up and the CD4 cell count falling. Exactly how this works hasn’t been clear to doctors and the investigators wanted to find out more.
 

First ever Viral Load - 'Baseline' - is good predictor

So they studied 1169 people for around 10 years. On average, CD4 cell counts fell by 66 each year. But the higher a person’s first ever viral load (often called the ‘baseline viral load’), the faster the person lost CD4 cells. And the more viral load increased from the ‘baseline’, the faster a person’s CD4 cell count fell.
 

10,000 or more

A person with HIV becomes vulnerable to potentially life-threatening illnesses when the CD4 cell count falls to around 200. The research showed that 96% of patients whose CD4 cell count fell to 200 had had a ‘baseline’ viral load above 10,000. And 86% of people whose CD4 count fell dangerously low, to around 50, started with their first viral load, the ‘baseline’ at 50,000 or so.
The researchers also found that falls in CD4 cell count predict increases in viral load.
 

“We show here that variability in CD4 cell count decline is linked more closely to viral replication than has previously been documented,” conclude the researchers.
 

Results help decide when to start treatment
This information may help people and their doctors decide when to start HIV treatment. If the first ever Viral Load, the 'baseline' was 10,000 or above, it makes even more sense to go for regular check-ups at the HIV clinic and to think seriously about starting treatment at a CD4 count of 350. Treatment should work better if it starts at 350, than if the CD4 count is allowed to fall below 350, before HIV treatment is started.

For more information on tests used to monitor health with HIV, you may find NAM’s booklet CD4, viral load and other tests helpful.
 

Source with reference