HIV treatment – prescribing in London
Changes have been announced by the NHS in London about the prescribing of antiretroviral therapy. The new agreement was developed to reduce the amount of money spent by the NHS on anti-HIV drugs and it applies from this month.
Patients in London who are starting HIV treatment for the first time and do not have drug resistance will now normally be prescribed a combination of drugs based on Kivexa (abacavir/3TC) unless there is a clinical reason not to prescribe it.
Reasons not to prescribe Kivexa include a patient having a viral load over 100,000 copies/ml, a positive genetic test for hypersensitivity to abacavir or being at high risk of a heart attack in the next ten years.
Therapy based on Truvada (tenofovir/FTC) will generally be prescribed for these patients. Truvada will also be given to patients with hepatitis B, and those being treated for hepatitis C.
People who start therapy with a protease inhibitor will now normally be given atazanavir (Reyataz) boosted by ritonavir (Norvir). Patients who are already taking a protease inhibitor may be assessed to see if they can change to atazanavir.
Atazanavir is easy to take (one capsule, once a day) and, unlike some other protease inhibitors, does not cause increases in blood fats (lipids). But a small number of patients develop a non-dangerous side-effect that can cause a yellowing of the skin and the whites of the eyes.
Ritonavir-boosted darunavir (Prezista) is recommended as an alternative for patients who cannot tolerate atazanavir.
It has been emphasised that no patient will be given sub-optimal treatment or therapy that involves a risk of serious side-effects.
Nevertheless, the change is controversial, especially the preference for abacavir.
This
drug was linked with an increased risk of heart attack in some studies, but
not all studies confirm this association (see the next item in this edition of HIV
Weekly) and it is only statistically significant in patients already at
high risk of heart attacks.
There’s also some evidence that abacavir might not be a good option for patients with a high viral load (over 100,000 copies/ml) and a very low CD4 count (under 50 cells/mm3).
HIV treatment – new study finds no evidence that abacavir increases risk of heart attack
US researchers analysed the results of six trials, and compared the risk of heart attack between patients who started therapy based on abacavir and individuals starting treatment containing a different drug.
All the studies included in the researchers’ analysis were randomised controlled trials. This meant that they were comparing patients with similar characteristics.
The risk of heart attack was analysed in the short term (one year) and the longer term (up to six years).
The findings of the study were very reassuring.
The overall risk of heart attack was very low. Moreover,
there was no difference in the rate of heart attack between people taking abacavir and
those on other treatments.
Factors associated with an increased risk of heart attack included older age, family history of cardiovascular disease, and smoking.
HIV treatment – suppressing viral load
Results of another study also have potential implications for the new London prescribing guidelines.
It involved approximately 1900 patients starting HIV
therapy, and showed that treatment based on abacavir may not be a good option
for individuals with a baseline CD4 cell count
below 50.
Viral load was more likely to remain detectable in patients with a very low CD4 cell count if they were taking abacavir compared to tenofovir.
Symptoms and illness – neurocognitive impairment
Some earlier research had shown that as many as 50% of patients with HIV have slight changes in their memory, thinking and movement. Often these were so mild that they weren’t noticed in daily life but could be picked up by tests.
These earlier studies caused alarm in some people with HIV as they seemed to show that even in the modern treatment era brain impairment was common.
However, some doctors doubted the validity of the findings and their significance in real life.
Just 19% of patients showed slight changes, similar to the 16% rate seen in the general population.
The patients in their study had an average age of 53 and had been living with HIV for a long time, but were doing well on HIV treatment and had an average CD4 cell count above 500.
Separate research involving young people who were born with HIV was similarly reassuring, and found they had rates of neurocognitive impairment no higher than their HIV-negative siblings.
Growing up with HIV
Thanks to the success of treatment, many children who were infected with HIV at birth have a good chance of living a long life.
The research showed that children can do very well on HIV treatment, with up to 95% having an undetectable viral load.
However, treatment with older anti-HIV drugs meant the side-effect lipodystrophy was common and facial wasting required surgical correction.
Some were having difficulty taking their treatment properly, and drug resistance was one of the factors associated with the few cases of mortality that are still seen.
Problems with emotional and mental health were common, and there was also evidence that some patients needed support regarding their sexual and reproductive health.
Hepatitis C – new drugs
Many people with HIV also have hepatitis C (sometimes called ‘co-infection’) and liver disease is a major cause of illness and death in these patients.
Treatment is available for hepatitis C and involves pegylated interferon and ribavirin, but it doesn’t always work. Treatment can also cause unpleasant side-effects.
New treatments for hepatitis C are being developed, and studies presented to a recent conference raised some questions about the future of therapy for hepatitis C.
These included how to use new
therapies; optimising
treatment with interferon; and the possibility of
interferon-free treatment.
However, little is known about the safety and effectiveness of new hepatitis C treatments in co-infected patients.