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

image credit

Late Diagnosis Gets Earlier

posted: 29/01/2010

Late HIV diagnosis will be sooner after infection, and a new stage of HIV infection, ‘advanced HIV disease’ is proposed for the UK.

‘Late diagnosis’ is fuzzy and confusing – it means different things depending on who you talk to. The boundary line of when diagnosis is late has also been shifting over time. UK experts are now saying we need to end the confusion and bring things up to date so we all talk about and mean the same thing. They looked at thousands of people diagnosed in the UK, their CD4 counts and what became of them.

Late diagnosis matters. Many people are diagnosed late and starting treatment late means you don’t get the full benefit of HIV treatment. People diagnosed late are more likely to get HIV illnesses and die sooner than people who start treatment at the best time. And people diagnoses late are more infectious and therefore more likely to pass on HIV without realising this.

The 'new late' : any CD4 below 350
A CD4 count of 350 is when most people in the UK should start treatment. The UK researchers now say that anyone diagnosed with HIV with a CD4 count below this 350 has a late diagnosis. In the USA, guidelines for treatment now say treatment should start when the CD4 count is between 500 and 350. It is likely that the UK treatment guidelines will soon say something similar. The benefits of starting treatment sooner are becoming clear.

‘Advanced HIV disease’
A new HIV disease stage is also proposed for the UK. If a person at diagnosis has any of the things that are associated with a higher risk of death within three months – such as a CD4 cell count below 200 or an AIDS-defining illness – they should be described as having ‘advanced HIV disease’.

Late diagnosis is a blight
Large numbers of people diagnosed in Europe and elsewhere are diagnosed late. Most of the HIV-related deaths in Europe are among people who were diagnosed late.

Diagnosing more people earlier would help cut the amount of HIV-related illness and death. Cutting late diagnosis would also reduce the spread of HIV - people who are diagnosed late have high viral loads and are more infectious.

What’s late?
Investigators from the UK Collaborative HIV Cohort (UK CHIC) looked at information on 15,774 people seen between 1996 and 2006 to find “a definition that can reliably identify a high proportion of individuals who will die shortly after their HIV diagnosis”.

Overall, 10% of people had a CD4 cell count below 50 cells/mm3 at the time of diagnosis, and another 17% had a CD4 cell count below 200 at diagnosis. But for 14% of the people in the study no CD4 figures at the time of diagnosis were available.

Just under 10% of people had an AIDS-defining illness at the time of their HIV diagnosis. For 2.4% of people this illness was moderate or severe and posed a significant risk of death.

Almost 4 out of 5 people with a CD4 cell count below 50 also had an AIDS-defining illness at diagnosis. Almost half the people with a more serious AIDS-defining illness had a CD4 below 200, but 4 out of 5 people who had a serious AIDS-defining illness at diagnosis had a CD4 count below 50.

206 (1.3%) people in the study died within three months of their HIV diagnosis.

More deaths with lower CD4, advanced illness signs 

The death rates were highest for all the disease stages the researchers now propose.

If your CD4 cell count is below 200 at diagnosis the mortality rate within three months is 3%. If the CD4 count at diagnosis is below 5o, the mortality rate after three months reaches 5%.

If you have an AIDS-defining condition when HIV is diagnosed then there is a 6% chance of death within the next three months. If you have a potentially life-threatening AIDS-defining condition at diagnosis then the risk of death rises to 10% within three months.

But a lot of useful data is missing – for 45% of the people who died there was no CD4 count.

Combining CD4 cell counts and clinical characteristics proved a more reliable guide than just looking at CD4 counts, or just looking at clinical stages of HIV illness. Using both together accounted for over two-thirds of the people in the study who died.

Late and advanced disease recommendations
“We propose that any individual who presents with either a CD4 cell count below 200 cells/mm3 or a clinical AIDS event is defined as presenting with advanced HIV disease”, write the investigators.

In addition they suggest that patients diagnosed with a CD4 cell count below 350 cells/mm3, or who develop an AIDS-defining illness within a month of diagnosis should be classified as having their HIV diagnosed late.

The investigators caution that a reliance on CD4 cell counts alone would not identify a substantial number of patients who have advanced HIV disease and a high risk of death at the time of their diagnosis. They write, “these patients may present and die without having their CD4 cell count measured”.

They hope that their proposed definitions will facilitate cross-country comparisons and help identify patients with a high risk of advanced disease at the time of their HIV diagnosis.

Source and Journal reference

image

How Long a Life Now?

posted: 26/11/2009

Thanks to the success of HIV treatment, many people with HIV are now living into older age. But how long will HIV+ people live? What can people with HIV reasonably expect?

No-one can predict accurately how long anyone will live, with or without HIV. All we can do is look for people similar to us and use their life spans as a guide.
 

Health harms

HIV is not the only thing that affects how long people live. There are a huge number of things that make a difference, from the genes we inherit from our parents, to our lifestyles – our drinking, eating, exercise habits, our weight, work, where we live, our general health - as well as things outside our control, like our class background and pollution.

Still improving

We know that life expectancy with HIV is still rising. Treatments are improving and there are good new drug prospects in the pipeline. Clinics will become better at managing HIV for older people, with more experience. Whatever life expectancy is now with HIV, we can expect it to continue to stretch nearer towards the length of life for people without HIV.

Making life sense

The information in recent studies seems confusing, but here we try to make better sense of it. We are doing this for two reasons

• people with HIV have a right to know, and
• HIV prevention messages based on a shorter life may discourage risk-taking by some people who are undiagnosed / HIV negative.

Large studies for the answers

Large studies comparing thousands of people with HIV with the rest of the population can tell us part of the answer to the 'how long will people with HIV live?' question.

Into 60s and beyond

One recent large international study found evidence that people taking HIV treatment can now expect to live into their 60s and beyond. The study showed someone starting successful HIV treatment aged 20 would be expected to live to be 63, and that someone starting treatments aged 35 could live to the age of 67.

It also showed the dramatic and continued decline in the risk of early death amongst people with HIV since effective HIV treatment began.

Starting treatment on time makes the difference

Importantly the researchers found that starting treatment with a CD4 cell count above 200 cells/mm3 means a person aged 20 could expect to live to be 70, and that a 35 year-old could survive into their 72nd year. Current treatment guidelines are to start treatment significantly earlier than CD4 200, and start instead at CD4 350.

• Age 20, start treatment at CD4 350  > can expect to reach age 70
• Age 20, start treatment at CD4 200  > can expect to reach age 63
• Age 35, start treatment at CD4 350  > can expect to reach age 72
• Age 35, start treatment at CD4 200  > can expect to reach age 67

10 years less, but earlier treatment adds years

Even in their most optimistic estimates, in this study the life-expectancy of HIV-positive people is about ten years less than for people who are HIV-negative. People who inject drug users and those who start HIV treatment later than recommended have shorter lives than other people with HIV – 20 years shorter for injecting drug users.
 

These results are from the Antiretroviral Cohort Collaboration - 14 large HIV cohort studies in Canada, Europe and the USA, of over 43,000 patients.
 

Late diagnosis and late starting of treatment cuts years from lives. 35 year-olds, starting treatment when the CD4 cell count is below 100 cells/mm3 can expect to reach 62, 67 if they start treatment at CD4 of 200, and by starting when CD4 is 350 (as now recommended) adds 10 years of life - to reach 72 years.

Source for the above 

Over 60s: old age, not HIV, causes deaths
A more recent study looked at people over 60 who live with HIV.

This French study found that over a four-year period, one in seven of the group died – but not a single death was due to an AIDS-defining illness – people died of ordinary diseases of old age.

The COREVIH Cohort is small, and started in 2004 with 149 patients drawn from six HIV clinics in the Paris area. Their average age at the start was 65. About 1 in 10 were in their 80s, the oldest being 86.

The average time since HIV diagnosis was 8.5 years, but this ranged from two months to 19 years.

Source for the above

Not dying soon after infection

A third study looked at deaths within five years of starting treatments. This large European study found no evidence that people died more than normal in the first five years of infection.

The European CASCADE 23 cohort collaboration, compared rates of death amongst HIV-positive people to death rates in the matching general population. It looked at 16,534 HIV-positive people infected with HIV between 1980 and 2006.

Most were infected with HIV via sex with another man (57%), 24% were heterosexual transmissions and 18% through injecting drug use.

They found that early deaths rates have been falling, and are continuing to fall, as treatments have improved. There is now almost no difference in death rates, at least within the first 5 years of infection.

But after the first five years early deaths are still a small risk. About 5 extra deaths in the first ten years of HIV infection can be expected among every 100 people. Extra deaths are more likely if people inject drugs – in the first ten years of infection more than 6 extra deaths can be expected.

Source for the above

USA: 21 years less - compare with 10 years less in European study
A recent USA study estimates people with HIV will die 21 years earlier than someone without HIV. This is very different to the best estimate from the study that included Europeans that we started this article with - which suggested 10 years less life with HIV.

Over 22,000 newly diagnosed people, from 25 of the 50 USA States (but not the major HIV states of New York and California) were included in the study.

They worked out how many years of life are lost, compared with someone of the same age, sex and ethnicity in the general population.

On average, life expectancy after diagnosis increased from 10.5 years in 1996 to 22.5 years in 2005.

HIV-positive women, had a longer life expectancy than men (23.6 years for women in 2005, compared to 21.8 years for men).
 

Among men, white men had the greatest improvement in life expectancy. USA black men diagnosed in 2005 could expect to live five years less than white men.

HIV+ white men’s life expectancy in 2005 = 25.5 years after infection (up from 10.3 years in 1996).
HIV+ black men’s life expectancy in 2005 = 19.9 years after infection (was 9.5 years in 1996).
USA gay men do best - life-expectancy for gay and bisexual men was for 28.3 years after infection in 2005. 
 

Injecting drug users have the shortest life expectancy (15.2 years for men, and 15.9 years for women in 2005).
 

Black women in USA in the early 2000s had a 20.6 year life expectancy after infection, and white women could expect 22.6 years.

The headline from this is that HIV appears to cut a USA person with HIV’s life by 21 years. This is very different to the best estimate from the study including Europeans we started this article with - which offers 10 years less life with HIV.

21 years is not as bad as it looks at first. Perhaps a significant part of the 21 less years is due to lifestyle differences between the people in the two studies, not HIV.

People who get HIV in the USA are far more likely to have a history of drink and drug use, have hepatitis C, and significant socio-economic problems, than the general population.

And many people with HIV in the USA don’t get all the HIV healthcare and treatment they need – there is no free NHS.

This means in the UK people with HIV on average would not lose so many years life as in the USA.
 

In this USA study, men could expect to die an average of 19.1 years before similar HIV-negative men, but this varies with your age. A man diagnosed aged 20 would die 25 years early, a 40-year old 18 years early, and a 60-year old 10 years early.

HIV-positive women lived an average 22.7 years less than women in the general population, but again this varies with your age. A woman diagnosed aged 20 would die 31 years early, a 40-year old 21 years early, and a 60-year old 11 years early.

Source for the above

What's this all mean?

We began by saying life-span prediction is not exact. We have a choice of two large studies looking at the years HIV cuts from life.

The first study suggests a loss of 10 years life is the best we can expect at present, but the last study, from USA, suggests you might lose 21 years of life. 

The two studies in the middle looked at slightly different things - would HIV kill you within the first few years after infection (answer: very unlikely) and the second looked at the causes of deaths in over 60s with HIV (answer: caused by old age, not HIV).

We think the truth, for most people diagnosed in the UK, is near to a loss of 10 years life. But this loss will shrink even more, with better treatments and better care for older people with HIV.

Treat early for a longer, better life with HIV

The biggest lesson is that once you have HIV, starting treatment as early as is recommended (at a CD4 count of 350) and taking HIV treatments properly will make the biggest difference to life length.

After HIV treatment, make your lifestyle healthier to reduce the risks of age-related ill-health damage (from smoking, drinking, drugs, lack of exercise, inadequate diet etc).

image credit - Caution Life Ahead 

image credit - 10 years ArtsMark

image credit -  Lifespan

Further information - prognosis factsheet from aidsmap

Hepatitis C and HIV - Treatment Urgency

posted: 17/08/2009

The key importance of starting HIV treatment at CD4 count of 350 is emphasised in a new study into how AIDS illnesses follow hepatitis C infection when you also have HIV. Some people with HIV also have hepatitis C, particularly gay men, people with haemophilia, and people who have ever injected drugs. Hepatitis C virus causes serious liver damage in many people, and liver disease is now an important cause of illness and earlier death in people with both HIV and hepatitis C.
 

Now researchers have found that having both HIV and hepatitis C doubles the risk of developing AIDS-defining illnesses as well. People who have cirrhosis of the liver (whether this is caused by hepatitis, or drinking alcohol) are even more likely to get an AIDS condition. Hepatitis C makes having HIV significantly more risky and worse for people.

AIDS illnesses become more likely

Liver disease, often due to hepatitis C or drinking, is now an important cause of illness and death in people with HIV. Hepatitis C infection has been linked with an increased risk of non-Hodgkin’s lymphoma, which is an AIDS-defining illness. However, does hepatitis C increase the likelihood of other AIDS-defining illnesses?. Italian researchers decided to investigate hepatitis C and links with other AIDS conditions. They found the risk was doubled, and is even worse for people whose liver shows cirrhosis damage.

Starting HIV treatment at 350 CD4 is a key guide

They say the best time to start HIV treatment needs to consider this doubled risk of developing AIDS illnesses. British HIV treatment guidelines recommend that HIV treatment should be started when a person’s CD4 cell count is around 350. People with HIV and hepatitis C co-infection are especially encouraged to start taking anti-HIV drugs at this time. Treatment delay can damage people's life expectancy and health prospects quite quickly.

The editorial in the journal says the study “highlights and strengthens the need for careful follow-up of hepatitis C-HIV-co-infected patients, including preventative methods (screening, prophylaxis, and vaccination of preventable diseases), effective management of co-morbidities…and early and effective therapies against HIV and hepatitis C virus.”

NamLife has a useful section on HIV and hepatitis C and treatment.

NAM produces an information booklet called HIV & Hepatitis.

i-Base also have a new Hepatitis C guide for people living with HIV

Source
 

CD4 Counts in Ugandan Rainforest

posted: 14/04/2009

"When I arrived here, I saw people with HIV being carried all day to get to the clinic," Paul Williams recalls. There were no testing services, no education, no treatment and certainly no monitoring of treatment. People just died."
 

That was the situation in Bwindi, Uganda, three years ago. Dr Williams, formerly a GP in North-East England, has since transformed a tiny and very basic health centre on the edge of the rainforest into an efficient community hospital.

And for the past five months, thanks to a small but important piece of equipment, Dr Williams' medical team has been able to monitor the health of patients with HIV from a clinic that fits into the back of their four-wheel-drive "community ambulance".

Bwindi Community Hospital now provides health care for about 40,000 people.
It has a dedicated maternity programme and a children's ward that deals with many cases of malnutrition, as well as other common diseases including malaria and HIV. In total, the hospital takes care of 1,000 HIV positive patients.
 

Treating HIV in the rainforest
Dr Williams describes the environment in which he works: "We're a mile away from the rainforest where there are mountain gorillas, right on the border between Uganda and the Democratic Republic of Congo. "There aren't any tarmac roads here, there isn't any public transport, and lots of the patients live a day's walk from the hospital. Many of them live a subsistence existence and they can't afford to get here."

So his team packs an "HIV outreach clinic" into its vehicle, and takes it out to remote communities.Along with the rest of the equipment loaded into the back and strapped on to the roof of the ambulance, there is one modest-looking grey box.
 

Portable and practical fast CD4 testing machine vital
This piece of equipment is a PointCare NOW machine. It was donated to the hospital last year, and has since transformed the care Dr Williams can offer HIV patients. The machine is a portable blood-testing device - pop in a blood sample and, within 10 minutes, it gives a print-out detailing the condition of a patient's immune system. It counts CD4 positive T cells. These are the white blood cells that the HIV virus latches on to - attacking and destroying them.
 

"When we say someone has a weak immune system because of HIV, we mean their number of CD4 cells is low," explains Dr Williams. "During the course of infection, the number of these cells gets less and less - so you have to count them to see how advanced the HIV is."
 

The quest for practical, cheap, quick, easy CD4 counts
The machine was developed by PointCare, a USA company that specialises in diagnostic equipment for the developing world. It's an organisation with an sound pedigree. Petra Krauledat, and her long-time business partner Peter Hansen, founded the company in 2003, having both already had long and successful careers in HIV research.

"Peter invented the first automated CD4 test in the late 1970s, and I led the group in 1982, in Germany, that launched the first HIV screening test in Europe," explains Dr Krauledat.
In the 1990s they were approached by former colleagues who asked them to turn their attention to developing a much-needed, cheap CD4 test for the developing world.
 

"So we went to Southern Africa to talk to the [medics] actually working there," she says.
What they found surprised them both. "People showed us tonnes of donated instruments just sat in storage. The reagents [or chemicals needed to run the tests] had simply perished in the heat," she relates. "So 'cheap' wasn't people's biggest concern. What they needed was a test that could be used in a little shack of a clinic, transported to remote areas, and that could withstand the high temperatures. We've fulfilled that quest."
 

Surviving the heat
Dr Hansen invented a test that uses chemical reagent that can be freeze-dried and stored in temperatures of over 40C. CD4 screening tests use antibodies - molecular tags that recognise and latch onto a chemical marker on the surface of the cell. By attaching to the cells, they act as flags distinguishing CD4 cells from other white blood cells. But these antibodies need to be "labelled", so they can be detected by a machine.
 

Traditionally, antibodies are labelled using fluorescent markers, but these fluorescent chemicals perish if they are not kept refrigerated. So they're useless for a medical team operating from a temporary clinic in the heat of an African summer.
 

Nanotechnology gold
Dr Hansen developed a new “label”. "We use colloidal gold," explains Dr Krauledat. "It's true nanotechnology - extremely tiny gold particles attached to the anti-CD4 antibody."
The gold-bound antibodies are very heat-stable - they can be stored at over 42C for an entire year.
 

Immediate result
Inside the PointCare machine, the freeze-dried, gold-labelled antibody is liquefied and combined with the blood sample, and with a chemical accelerator that speeds up the attachment of the antibody to the cells. "How the accelerator works is a trade secret, but it allows us to complete the test within eight minutes," says Dr Krauledat.

"Before we had this machine, we'd see somebody in the clinic, then we'd have to see them on another day to collect a blood sample," recalls Dr Williams. We had a system of motorcycle riders that went round all of our outreach sites on a particular day to collect samples. They would have to ride for four hours along a muddy road through the rainforest, to a laboratory on the other side, where we could get them tested. It took us three days to get the result, and we couldn't get it back to the patient until we saw them again two weeks later. Now, with this simple piece of technology, we can deal with problems immediately."
 

The machine is also far cheaper to run than traditional instruments. It is powered by a battery pack. "Because we use colloidal gold, we have an instrument that doesn't consume a lot of power," explains Dr Krauledat. The standard technology [which uses fluorescently labelled antibodies] means they have to be detected with a laser, and those systems are quite fragile and consume more power. We use a [light-emitting diode] detector. It's technology with a lifetime of 180,000 days, doesn't break and it uses almost no power."
 

Complete picture given with 5 other blood counts
As well as a CD4 count, the device also counts five other subtypes of white blood cell. This gives a complete picture of the patient's immune system.
 

The results provide a physician with a good indication of whether an HIV positive patient might have tuberculosis, give a warning sign of other opportunistic infections, and find out if the patient has anaemia - a debilitating condition that is fairly common in the latter stages of HIV.
It also means that a patient's treatment can be monitored. "HIV treatment is great - anti-retroviral drugs can add up to 30 years to a person's life," says Dr Williams. But there are some people who develop resistance to the drugs, or in whom the drugs fail, and we can spot that early on to take action to be able to stop them from getting sick."
 

3 years has changed community's life prospects

In three years, Dr Williams and his team have transformed the lives of their HIV positive patients.
"I started a testing centre in the hospital, then the mobile testing services, and then, once we had access to drugs, developed a treatment programme. Now our death rates from HIV are very low. We're able to diagnose it early, manage it early and keep people living with HIV fit and well. Over a reasonably short period of time, we've been able to change HIV from being a death sentence into something that people can live with and lead productive lives."

Source

Report on the development of an easier and cheaper system for CD4 checks