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

New Treatments Pipeline

posted: 10/09/2010

If you want to know about all the future treatments, tests, and prevention for HIV, hepatitis, and TB, the Treatment Action Group (TAG) have produced a new guide. It deals with

• future HIV antiretroviral treatments
• future ways of diagnosing HIV
• future HIV antiretroviral treatments for babies, children and young people
• future immune-based therapies and preventive technologies - like vaccines and pre-exposure prophylaxis (which means treatment to prevent HIV infection)
• future hepatitis B treatments
• future hepatitis C treatments
• future diagnosis, treatments and vaccines for tuberculosis (TB)

It's not an easy booklet to read, but there are 150 pages of information about new HIV treatments in the development 'pipeline.' That is a lot of new developments that should continue to steadily improve the quality and length of life people with HIV can expect.

TAG 2010 Pipeline Report from i-BASE

Treatment Action Group (TAG)

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

HIV - Treat to prevent?

posted: 06/04/2010

The use of HIV treatment for preventing HIV is a hot – and controversial – topic. Now researchers are saying people with HIV should not stop using condoms and start depending on HIV treatment to protect their partner until you have taken treatment and the viral load has been undetectable for at least 12 months.

 
Some, perhaps most, people who are taking HIV treatment, who do not have sexually transmitted infections and who have an undetectable viral load, are not infectious to their sexual partners.

Some of the research suggests that taking HIV treatment and keeping an undetectable viral load is at least as good as using condoms in preventing HIV. Not everyone agrees, and there are heated debates about this at HIV conferences.
 

The debates started about two years ago with what is now called the Swiss statement - it was followed by broadly similar statements from France, Germany and the USA.

Reliably undetectable?
Danish researchers wanted to see if people taking HIV treatment can rely on their viral load remaining undetectable. They looked at the viral load results of every person in Denmark who was taking HIV treatment. Research shows that HIV transmissions are very rare if a person had a viral load below 1000 copies/ml. So they assumed that everyone taking HIV treatment with a viral load above this is potentially infectious. They then calculated the amount of time that people taking HIV treatment had an ‘infectious’ viral load of above 1000.
 

Reliable for most

For people who reached an undetectable viral load, it stayed undetectable 99.5% of the time.
But during the first year of HIV treatment, viral load can suddenly increase to detectable levels – this happens for about 5% of the time. People won't know when their viral load has taken an upward, detectable, blip when HIV transmission becomes more likely.

The risk of transmission was especially high during the first six months of HIV therapy, when 8% of the time was spent with a viral load above 1000 copies/ml. During the next six months, viral load was at potentially infectious levels for a little over 1% of the time. After the first year viral load was only above the potentially infectious threshold for an average of 0.6% of the follow-up period. After five years, only 0.03% of the follow-up period was above 1000 copies.

Different routes of transmission do not seem to make a difference - except for injecting drug users who had a potentially infectious level of viral load 1.5% of the time. The researchers belive this is because of poorer treatment-taking among injecting drug users.

Wait until viral load stays undetectable for 12 months

They therefore think that the Swiss recommendation about using treatment for HIV prevention should be tightened. They believe people should not swop condoms for treatment until there has been an undetectable viral load for at least twelve months, twice as long as suggested in the Swiss statement.
 

Sexual Transmitted Infections and viral load

Sexually transmitted infections can cause undetectable viral loads to suddenly become detectable - especially in the genital fluids. We measure all our viral load samples from the blood but what passes on HIV is HIV in the genital fluids. Many people have undetectable HIV in the blood but can have a detectable viral load in the genital fluids - and these are the ones that transmit HIV in sex. Sexually transmitted infections cause detectable genital viral loads and make us more infectious. Some experts say that among groups of people with high rates of sexually transmitted infections, such as gay and bi men with HIV, undetectable viral load is too unreliable to judge your risk of passing on HIV.

Swiss reminder

The debate on treatment as prevention was kick-started a little over two years ago by the release of what is known as ‘the Swiss statement.’
Senior Swiss HIV doctors and researchers said that HIV-positive individuals who were taking HIV treatment were not infectious to their sexual partners if:

• Their viral load had been undetectable for at least six months.
• They took their HIV treatment properly.
• They did not have any sexually transmitted infections.

Source

Treatment Booklet Updated

posted: 18/03/2010

The latest issue of NAM’s booklet, anti-HIV drugs, is just out. It tells you about each of the drugs currently licensed for HIV treatment in the UK.
 

All the booklets in this series are free to people living with HIV in the UK, or can be ordered through the aidsmap online bookshop for £1.

You can read it online, or download the booklet as a pdf.

Colour HIV drugs chart - new edition

The new edition of their full colour HIV drugs chart (February 2010 edition) is also now available to download as a pdf.

Clinics and HIV support groups
If you work in a clinic or support group in the UK, you can order these booklets for free for your clients and patients. Get in touch with Rose for details on 020 7840 0060 or by emailing her.

For the experts - HIV Treatment Directory
The new edition of the HIV Treatments Directory (28th edition) is also now available.
 

A complete reference guide to HIV treatment and medical aspects of HIV, with A to Z listings and an intuitive layout. Comprehensive information, and details of published research covering topics including:
• starting and changing treatment
• A to Z of antiretroviral drugs
• women's health issues
• drug resistance
• drug interactions and pharmacokinetics
• HIV and genetics
• side-effects
• the immune system and HIV
• prevention of mother-to-child transmission
Plus a full-colour drug chart and CD-ROM.
 

To order your copy, please visit NAM's webshop 
 

People's price

It costs professionals a few pence under £65 but people with HIV can buy it for £12.95 – it’s free but this is the cost of special delivery for this large, heavy book.

The Treatments Directory is excellent but has much more information than most people with HIV want. George House Trust has a copy you can use in our reception area.