Anti-HIV treatment

New UK guidelines for starting anti-HIV treatment

HIV is a very specialised area of medicine. Leading HIV doctors from across the UK therefore prepare guidelines to help make sure that people with HIV receive the right treatment and care.

A new version of the treatment guidelines has just been prepared, and earlier this week Prof Brian Gazzard, one of the UK’s most senior HIV doctors, talked about them at a NAM information forum.

There are some important changes since the last guidelines, and these changes are mainly concerned with when to start anti-HIV treatment and what to start treatment with.

According to the new guidelines, anti-HIV treatment should be started as soon as a person feels able to after their CD4 cell count has dropped to 350. People with any of the following characteristics are particularly encouraged to take treatment at this time:

• Viral load above 100,000.
• Age over 50.
• Risk factors for heart disease.
• African origin with any evidence of kidney disease.

The benefits of earlier treatment were apparent in the SMART HIV treatment interruption study which showed that people with a CD4 cell count of 350 and above were much less likely to develop not only HIV-related illness, but also other serious illnesses such as heart, kidney and liver disease, than people with a CD4 cell count around 200, the previous threshold for starting anti-HIV drugs.

The guidelines state that the preferred combination when starting anti-HIV treatment is efavirenz (Sustiva) with Truvada(tenofovir and FTC). A ritonavir-boosted protease inhibitor is an alternative for some patients.

Truvada is preferred to Kivexa(abacavir and 3TC) mainly because there is some evidence that Kivexa may not work as well in people with a high viral load.

Abacavir

A big study recently showed that treatment with abacavir (Ziagen) or ddI (Videx) increased the risk of heart attack, particularly for people with existing risk factors for cardiovascular disease.

The draft UK guidelines refer to this study and recommend that doctors should be cautious about treating people with a risk of heart disease with abacavir.

But the study suggesting that abacavir increased the risk of heart disease was not complete. In particular, it didn’t look at the heart disease risk of the main competitor to abacavir - tenofovir or the risks associated with another important anti-HIV drug, FTC.

And the makers of abacavir, the drug company GlaxoSmithKline (GSK), have looked at the results of 54 trials they conducted into abacavir and did not find any evidence that the drug increased the risk of heart attack.

Nevertheless, a leading heart specialist writing in The Lancet commented that, although the GSK results were reassuring, there weren’t enough people in the studies for the results to be conclusive. He recommended that abacavir should be used with caution in people with a risk of heart disease.

A known side-effect of abacavir is an allergic, or hypersensitivity reaction. It affects between 5% - 8% of people who take the drug. People who experience a hypersensitivity reaction to abacavir who stop taking the drug must never take abacavir again as this can lead to a potentially fatal drop in blood pressure.

Allergy to abacavir is associated with a gene called HLA-B*5701 and everyone who is considering treatment with abacavir should have a test to see if they have this gene. The gene is more common in white people than black people.

There was concern that this test didn’t work as well in black people than white people, but a new study has shown that this isn’t the case.

Response to anti-HIV treatment

The aim of anti-HIV treatment is to suppress the amount of HIV in the blood to undetectable levels. This allows the immune system, measured by the number of key CD4 cells, to strengthen.

But some people experience neither an undetectable viral load nor an increase in their CD4 cell count. Some other people have what is called a “discordant response” to anti-HIV treatment. That’s to say they only have an undetectable viral load, but no increase in their CD4 cell count, or an increase in their CD4 cell count, but not an undetectable viral load.

Doctors in America have found that, compared to people who have both an undetectable viral load and an increase in their CD4 cell count, those with a discordant response to anti-HIV treatment have an increased risk of illness or death.

But even if you do have a discordant response to treatment, your risk of becoming ill because of HIV is much lower than if you weren’t taking any anti-HIV treatment at all.

New atazanavir prescribing information for kids

Medicine regulators in the US have issued new advice about the use of the protease inhibitor atazanavir (Reyataz) in children aged under 18.

The Food and Drug Administration now recommends that atazanavir should not be given to babies aged under three years of age because of a dangerous side-effect that can affect the brain in small children.

Atazanavir capsules should not be given to children under six; children under 13 without ritonavir boosting; and to children who’ve taken anti-HIV treatment before and weigh under 25kg.

Doses of atazanavir capsules in children depend on weight, and the drug should be taken with food.

You and your doctor

Anti-HIV treatment and care is provided by doctors who specialise in HIV. It is very important that you see your doctor for regular check-ups. There may be times when you and your doctor disagree about things and developing a way to deal with these situations is important.

French research suggests that nearly all patients have a trusting relationship with their doctor after starting anti-HIV treatment. A small number of people lost trust in their doctor. The reasons for this included: not believing that anti-HIV treatment really worked; not receiving information about anti-HIV treatment; experiencing a lot of treatment side-effects; and smoking.

At the NAM forum, Prof Gazzard said he was concerned that a lack of belief in the benefits of anti-HIV treatment was leading to unnecessary HIV-related deaths.

You can get impartial HIV treatment information from NAM’s website, www.aidsmap.com and THT also produce a number of useful treatment guides.

Researchers think that some patients may have lost trust in their doctor after being told not to smoke. There’s information on why it’s a good idea to stop smoking if you are living with HIV here, and some tips on how to stop, here.

Clinical trial needs your help

Researchers at King’s College Hospital in London are asking for your help.

Some people who are exposed to HIV seem to be protected against infection with the virus. Researchers want to find out if this is just down to chance, or if these people have natural abilities that enable them to fight off the virus. They are hopeful that their research could help in the search for a vaccine against HIV.

If you or your partner can answer yes to the following questions, you may be able to participate in this study:

• In a relationship where one is HIV-positive and the other HIV-negative or untested?
• In this relationship for at least ten months?
• Both willing to take part in the study?
• Both willing to give blood and urine samples?

All you would need to do is answer some questions about your relationship and then provide blood and urine samples. Researchers will use this information and these samples to examine genetic and immune factors in the body. Participating in the study would involve you coming to King’s College Hospital on two or more occasions. At your initial consultation the details of the study will be explained to you in full. You will be given some cash to compensate you for your time and for your travel expenses.

You can find out more about this important research here, or by contacting Sara Okumu : 020 3299 3479; sara.okumu@kch.nhs.uk.

Jobs at NAM

We are entering an exciting period during which we seek to enhance the relevance, accessibility and reach of our materials to meet the changing needs of people with HIV and HIV sector professionals.

NAM is now recruiting for five new posts:

• Editorial Team Manager
• Editor, HIV Services in the UK
• Sub-editor
• Web Developer
• Graphic Designer (web & print)

Download the application packs online here.

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