HIV update - 12th December 2019

More gay men know that U=U

A recent large study has found growing awareness and acceptability of the Undetectable = Untransmittable (U=U) message among gay and bisexual men in the United States. However, a misunderstanding of transmission risk remains, with many still believing that HIV-positive partners can transmit the virus sexually, despite having an undetectable viral load.

While over half of the 111,747 men who completed the survey perceived U=U to be accurate, many of those who thought so were HIV-positive men. The majority of men living with HIV (84%) perceived U=U to be somewhat or completely accurate. This was in contrast to only 54% of HIV-negative men and 39% of men who did not know their status. Nearly a quarter of HIV-negative men stated that U=U was completely inaccurate.

Data was collected at various times in 2017 and 2018 and, encouragingly, trust in U=U increased over time. The odds of increased belief in U=U increased each month by 2% for HIV-negative men and 3% for HIV-positive men.

Among HIV-negative men, an accurate understanding of U=U was associated with taking PrEP, regular HIV testing, sex without a condom and recreational drug use. It seems that those with more exposure to prevention and testing services are more likely to rate U=U as accurate.

For more information, read NAM's page 'Undetectable viral load and transmission – information for HIV-negative people'.

Tenofovir and cholesterol

Tenofovir disoproxil fumarate (TDF) is one of the most widely used drugs in HIV treatment. It is included in the pills Truvada, Eviplera, Stribild, Atripla and Delstrigo. There is also a new form of the drug, called tenofovir alafenamide (TAF), which is included in the pills Descovy, Odefsey, Genvoya, Biktarvy and Symtuza.

The newer form of the drug has been promoted as having fewer side effects than the older one. In particular, whereas TDF can make kidney and bone problems worse for a few people, TAF is gentler in those respects.

However, we are starting to realise that TAF has other effects. The newer form of tenofovir appears to cause increases in total cholesterol, LDL (‘bad’) cholesterol and triglycerides in some people who take it. Increases in these lipids (body fats) are associated with heart disease. It’s also possible that TAF is linked to increases in body weight in some people.

Doctors in Germany wanted to see whether increases in cholesterol and triglycerides could be reversed. They looked specifically at 168 people who had been doing well on HIV treatment that included TDF. They all switched to TAF and then switched back to TDF again a few months or years later.

Lipids increased in over two-thirds of those making the first switch, but levels fell back again after reverting to TDF, especially in people who had experienced the biggest increases after the first switch. This should be reassuring news for anyone thinking about switching to a regimen containing TAF, or who has seen their lipids increase while on the medication.

For more information, read NAM's page 'Cholesterol'.

Stunting is common in adolescents living with HIV

A research study has shown a high prevalence of poor physical growth among HIV-positive adolescents living in sub-Saharan Africa, Asia-Pacific and Central and South America. This is called ‘stunting’ and refers to young people who are much smaller than the average for their age. It is sometimes caused by inadequate nutrition and recurrent infections or chronic diseases which cause problems with the way the body handles nutrients.

The study included 8737 adolescents living with HIV. All participants had been born with HIV, were taking antiretrovirals and had been receiving HIV care before they had reached ten years of age. Of the study sample, 85% started antiretrovirals after five years of age. When HIV therapy was started, 50% of the adolescents had stunted growth, half of whom were severely stunted.

A late start of antiretrovirals, a lower CD4 cell count and malnutrition were shown to contribute to stunted growth. HIV treatment reduces vulnerability to other HIV-related illnesses that adversely impact growth.

Throughout adolescence, stunting disproportionately impacted boys. Evidence also suggests poorer growth among boys in rural areas (compared to boys in urban areas). Further work is needed to understand these gender differences.

A large proportion of the study participants had entered HIV care before immediate treatment had become a universal recommendation. With better access to paediatric care and with more children starting HIV treatment earlier, it’s possible that stunting will become less common in the future. Starting antiretrovirals earlier and better access to medical care helps prevent stunted growth, although early access to HIV treatment varies from region to region globally.

HIV in the over-75s

When people talk about “HIV and ageing” they are often referring to people over the age of 50. Not much attention has been given to people living with HIV in their seventies and eighties. This is partly because while there are a lot of people living with HIV in their fifties and sixties, there are still relatively few people with HIV in the older age groups.

But one group of French doctors have focused on people living with HIV over the age of 75 (2% of all people with HIV in the region they studied). They found that three-quarters were men, just over half were single and almost all were living in their own home. Many had been living with HIV for 20 years or more, with a third having been diagnosed with AIDS at some time in the past.

All were taking HIV treatment and 98% had an undetectable viral load – a better figure than in younger people. But most were living with another health condition and were taking medication to treat other illnesses.

For more information, read NAM's page 'HIV and the ageing process'.