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

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

Asylum Support Section 4 Changes

posted: 13/11/2009

Important changes were made to Section Four Support on 14 October, by the UK Borders Agency. These changes are likely to cause serious difficulties for destitute asylum seekers.

On 14 October the UKBA introduced a surprise new policy for Section 4 support for people who apply for it on the grounds of making a fresh asylum claim. These changes apply immediately and may cause serious difficulties for destitute asylum seekers who are applying for support.

Read the detailed factsheet from the Asylum Support Appeals Project.

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