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

HIV and Mental Illness - Positive Solutions

posted: 16/11/2009

Stigma often represents the most crucial element effecting people living with a wide range of illnesses. It negatively affects efforts to treat and prevent disease, and adversely affects individuals’ quality of life. The type of stigma varies with different conditions. This article highlights some causes and differences between the stigma associated with mental health compared with HIV, as well as successful strategies of reducing its impact.

Definitions of stigma include

• social identity (deviance from what is normal),
• power discrepancies (that allow discrimination), and
• discrediting attributes that devalue people living with certain illnesses, such as HIV.

Stigma often appears as discrimination, hatred, intolerance, rejection, and exclusion.

Unrecognised internal stigma damages
However what is often under-recognised is the internal aspect of stigma. Internal manifestations can include self-loathing, shame, and self-blame – an intention behind the stigmatising comments and actions. The stigma can spread to others associated with the stigmatised individual or condition – such as family, friends, and even to institutions and clinics. As a result anyone associating with patients, or visiting centres, can be dragged into the net of stigma.

It can be helpful to consider stigma in other conditions so we can understand how it works differently (or the same) in HIV better. The article next considers people living with mental illness. People who have depression, schizophrenia, and other mental illnesses, commonly report stigma from both community and health professionals. Depression and schizophrenia affect millions of people. Of these, only 25% of those with depression, and 50% of those with schizophrenia who are in need of treatment are getting the right treatment. This suggests that stigma, at least in part, may be having an affect on treatment of mental illness. The perception of depression as a weakness rather than an illness; or that people with depression are dangerous, and ‘schizophrenics’ are violent remains deeply embedded in public opinion.

Why are many other conditions NOT stigmatised?
Stigma is far less likely with other common illnesses for example cardiovascular disease. Unlike mental illnesses, cardiovascular disease is less stigmatised at least in part because the causes, disease development and successful treatments are well known.

Does Fear of the Unknown  makes Stigma stick?
The fear of the unknown may be what makes stigma stick to certain illness. This makes people afraid to tell family and friends, and not seek help when they need it. Health staff, even those in mental health can also stigmatise through intensive use of language and labelling. Some healthcare staff show more human empathy and understanding, but some define the person by their illness. The difference in language is powerful – a ‘schizophrenic’, whose behaviour defines them, versus a ‘person living with schizophrenia’, whose illness causes altered behaviour. This labelling may plague the patient as a ‘life sentence,’ reducing self-esteem, withdrawing social opportunities, and creating ongoing employment difficulties, ultimately ruining any chance of normality.

People living with HIV
Many people with HIV across the globe are not on treatment that is needed. One of the biggest issues preventing treatment uptake is stigma. However, the stigma signature associated with people living with HIV is different to that explained for mental illness.

Bos and colleauges suggest how stigmatisation of people living with HIV works. They describe how

• perceived contagiousness (everyday contact, not just sex),
• perceived seriousness (life-threatening),
• personal responsibility (unsafe sex) and
• norm-violating behaviour (e.g. male-to-male sex, and intravenous drug use)

all contribute to increase fear and anger, while decreasing pity for people living with HIV.

Stigma also surrounds certain groups at increased risk, such as

• homosexuals,
• intravenous drug users,
• migrants, and
• sex-workers.

This further stigmatises people living with HIV leading to yet more discrimination and negative social responses. As a result, people living with HIV have a lower quality of life and are less likely to test, get treated, seek advice, information and counselling, or disclose their status to people who could help with support. This can result in late diagnosis with high viral loads, low CD4 counts, and opportunistic infections.

Strategies for Reducing Stigma
The need to deal with stigma is paramount to reducing the HIV epidemic, and increasing treatment uptake.

Accurate knowledge and portrayals of HIV survival and recovery, as well as the true risk to the community from HIV needs to be thoroughly promoted especially in the media.

Telling others helps
Public disclosure of HIV status helps both the individual and the surrounding community. Individuals are often very scared and describe this as the most difficult and dangerous thing to do. After telling people feel empowered, released from a heavy secret, and less isolated and withdrawn, taking back control of their lives.

To help facilitate this appropriate training and support needs to be given before disclosing to prepare for potential negative reactions from people. However, public speaking regarding one’s positive living helps to make the community more aware and dispel myths around HIV, thus reducing stigma. This is echoed by studies involving public speaking by people living with HIV and mental illness, which have shown improved attitudes among high school students to those living with the illness.

One Voice
Uniting all people with stigmatised illness would provide a voice that would be far too loud to ignore.

Access to relevant treatment that communities understand is effective and essential in any stigma reduction programme. Universal access to HIV therapy in Botswana (which has the 2nd highest prevalence), implemented in 2002, provides clear evidence of reducing stigma. Wolfe and colleagues demonstrated pre- and post-implementation that only 31% of people had disclosed positive HIV status to family, and 5% to friends in 2001, compared with 90% and 55% respectively in 2004. Other examples of reduced stigmatising attitudes include an increase in the number of people that would care for a person living with HIV, accept them as a teacher and buy food from a shopkeeper with HIV.

Conclusion
Stigma and its consequences affect the course of illness for many millions of people worldwide. It provides an enormous barrier to all attempts to help people living with stigmatised illnesses. Stigma affects all, it endures, and it compromises survival and recovery of those most in need. We must strive to find new ways to abolish stigma, and thereby allow access to treatment and empowering positive living.

Source with detailed references – full article online free