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

Growing Life Expectancy

posted: 15/12/2010

Life expectancy with HIV continues to improve. People diagnosed during 2006-08 in the UK who then keep a CD4 count of over 200, now have a life expectancy with HIV the same as the general population. This was the good news from research presented at the 10th Congress on Drug Therapy in HIV Infection in Glasgow this month.
 

Ending late diagnosis would add 10 years

The bad news was that late diagnosis of HIV is still a serious problem in the UK. If everyone with HIV were diagnosed before their CD4 count fell below 200, this would raise life expectancy with HIV in the UK by an astonishing ten years.
 

Average life 13 years less – because so many people are diagnosed late
HIV still cuts 13 years off the average person’s life expectancy, the conference heard, although ten of those lost years are due to people coming for testing late, with CD4 counts already under 200.
 

Men’s average life expectancy loss is twice women’s
Men’s average loss of life expectancy due to HIV is twice that of women. Men tend to neglect their health more than women and are not routinely screened for HIV, whereas sexually active heterosexual women are routinely tested in pregnancy.  Late diagnosis is more common among men affecting men's average life expectancy. 

A great many deaths due to HIV in the UK are simply because people tested late. The death rate in the first year after being diagnosed with a CD4 count already under 200 is 5 times higher. But people who keep a CD4 count over 200 are living longer. People diagnosed in the last 10 years lost 6.5 years on average compared with the general population, and this is still improving. In the last two years the lifespan for people with HIV who keep a CD4 count over 200 has become near-normal, presenter Margaret May said.
 

UK study shows rising life expectancy

The Glasgow conference was hearing results from the UK CHIC cohort study which uses data from 30 different HIV clinics in the UK.

They looked back at nearly 18,000 patients who started HIV treatment between 1996 and 2008. They left out the people most likely to have the highest and lowest life expectancies, the people who started HIV treatment when their CD4 count was above 350, and injecting drug users.
 

Three-quarters of the group were male, 58% gay men, and 60% white. The median age for starting treatment was 37 and the average CD4 count for starting treatment was 166.
Seven per cent,1248 people, died and they worked out the death rates for each of four three-year periods (1996-99, 2000-02, 2003-05 and 2006-08).

These were used to work out an artificial standardised mortality - life expectancy at age 20: the remaining years of life that a person could expect at their 20th birthday, regardless of their age when diagnosed with HIV.
 

Rising life expectancy
During the earliest period (1996-99 when effective HIV treatment started improving life expectancy) life expectancy was 30 years; in other words, a person diagnosed with HIV between 1996-1999 could expect, if they were 20, to live until they were 50. (Please do not panic if you were diagnosed during these years and are now in your late 40s. You should have more than a few years left: life expectancy rises as we age, because people who survive are more likely to continue to live.)
 

People diagnosed between 2006-08 on average have seen a one-third improvement to 46 years; in other words, they could expect to live until 66.
 

Fewer years than the general population
However, this is still 13 years less than the average life expectancy at age 20 in the general UK population. In the general population the life expectancy difference between men and women has narrowed, with improvements in early death due to heart disease in men, to only two years; a 20 year old man can now expect to live till 80 and a woman till 82.
 

But in the population of HIV-positive people as a whole, men have a life expectancy at age 20 of 40 years (implying that a man diagnosed with HIV can expect to live until the age of 60) and women of 50 years: exactly why this is the case will take more research.
 

Life expectancies are continuing to rise, however. For people diagnosed with HIV during 2006-08 who keep a CD4 count of over 200, life expectancy at age 20 is now equal to that in the general population.
 

Margaret May said that if everyone got diagnosed with a CD4 count of over 200, this would improve life expectancies by ten years.
“In conclusion,” she said, “we join the advocacy for improved diagnosis and timely treatment, which could improve the life expectancy of people with HIV in the UK.”
 

Conference website

Image Get Tested, Live Longer

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

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