Time spent in hospital waiting rooms is time well spent
Having HIV means having to go to the hospital – a lot. It can be inconvenient, time consuming, and physically and emotionally uncomfortable. But a study published last week showed why it’s important to overcome these issues and just how important it is to regularly go to your HIV clinic for check-ups and tests to see how well your HIV treatment is working. To put it simply, the study found that people who attended their appointments lived longer and had the best response to HIV treatment.
To find out how to get the most out of your HIV clinic, and what to do if you’re not happy with your treatment and care, you might want to read these NAM factsheets: HIV clinic services; you and your doctor; and complaints about NHS services and treatment.
If you’re worried about your entitlement to free NHS care, and this is deterring you from getting proper HIV care, you might be reassured by reading this leaflet.
Try and make sure you see your HIV doctor regularly – it really could save your life.
Genital warts vaccine
Many people with HIV are infected with a virus that causes genital warts. This virus is called human papilloma virus (HPV), and certain strains of it can cause cancerous cell changes in the cervix and anus. Both anal and cervical cancer are seen more often in people with HIV than in the general population. Anti-HIV therapy has no effect against HPV, but there is some good evidence to suggest that by strengthening the immune system, HIV drugs can help the body fight off HPV.
There has recently been a lot of excitement about the development of a vaccine against the strains of HPV that are particularly associated with cervical cancer. Late last year, one such vaccine, Gardasil, received formal approval in the UK after trials showed it was highly effective in some circumstances.
It is still being decided how best to use this vaccine.
Clinical trials are conducted under very strictly controlled conditions, so the researchers also wanted to see how the vaccine would perform in a ‘real world’ setting in women who were excluded from the trial because they were already sexually active and were already infected with the strains of HPV that the vaccine is intended to protect against. The researchers found that it was 34% effective at protecting against the development of anogenital warts, 44% effective at protecting against pre-cancerous cell changes in the cervix, and 17% effective at protecting against cell changes caused by other types of HPV.
It is important to note that these trials did not include HIV-positive women so it isn’t known how well the vaccine will work if you have HIV. Nor did the study look at the effectiveness of the vaccine in men.
There is anecdotal evidence that some gay men in London and the United States have been seeking vaccination with Gardasil from private doctors at a cost of around £450. Vaccination is being provided without first testing men for infection with the strains of HPV the vaccine is intended to protect against, and as most, if not all those seeking private vaccination will already be sexually active, it is highly questionable just how effective the vaccination will be in these men.
NHS vaccination with Gardasil will commence once it has been decided how it can be best used.
Further studies are planned to look at how effective the vaccine is in men, and in people with HIV.
Oral and throat cancer
Oral sex with several people and infection with certain strains of HPV increases the risk of oral and throat cancer, according to research.
It had previously been thought that smoking and heavy drinking were the biggest risk factors for oral cancer, but the researchers found that having HPV-16 infection in the mouth or throat was actually a much bigger risk.
People with six or more oral sex partners in their life-time were also more likely to have throat or oral cancer – probably because the more oral sex partners you have, the more likely you are to get oral infection with HPV.
Hepatitis C
A study has found that infection with hepatitis C virus increases the risk of developing non-Hodgkin’s lymphoma.
Hepatitis C can cause permanent scarring of the liver (cirrhosis) and liver cancer, and researchers wanted to see if it also increased the risk of blood disorders and lymphomas.
Their research did not include people who had HIV as well as hepatitis C. This was because non-Hodgkin’s lymphoma is a recognised AIDS-defining cancer.
The researchers matched people with hepatitis C-negative people of a similar age. They found that those with hepatitis C were 28% more likely to develop non-Hodgkin’s lymphoma. The researchers think that monitoring people with hepatitis C for blood disorders could mean that the risk of non-Hodgkin’s lymphoma is reduced.
The importance of going to your HIV clinic
It is important for people with HIV to take responsibility for looking after their own health. It's well known that you can increase your chances of living a longer and healthy life with HIV if you attend a specialist HIV clinic. And taking your anti-HIV medication properly is the single most important thing you can do to ensure that you gain the maximum benefit from it.
US researchers from the Department of Veterans Affairs, the largest single provider of (free) HIV care in the US, wanted to see if regularly attending scheduled clinic appointments improved a person’s chances of survival. They assumed that this would be the case, but they noted that this hadn’t been examined in any earlier research.
They logged the clinic attendance of patients for the first year after their HIV diagnosis and then looked at their subsequent survival. Details of how well patients did on anti-HIV therapy were also recorded.
The researchers found that gains in CD4 cell count and falls in viral load were greatest in patients who kept all their clinic appointments. They also found that the risk of death increased with the number of quarterly clinic appointments a person missed. People who kept all their appointments had the lowest risk of death and those who missed three of their quarterly check-ups the greatest risk.
According to an editorial that accompanied the research, services such as transport to clinic appointments, treatment for problematic drug use, mental health support, and specialist case workers could help make sure that people stay in touch with their HIV clinic.
Mother-to-child transmission of HIV
It is possible for a mother to infect her baby with HIV in the womb, during birth, or by breastfeeding. But the risks of this happening can be reduced significantly by the use of anti-HIV drugs, by having a caesarean delivery if the mother has a detectable viral load, and, in countries like the UK where safe alternatives are available, by not breastfeeding.
French researchers wanted to see if the risk of mother-to-child transmission was increased if a mother had twins. Their study involved all pregnancies involving a mother with HIV in France between 1984 and 2004. They conducted their study because more woman are having twins, and being pregnant with twins increases the risk of going into premature labour, which can mean that a mother can’t have a caesarean to reduce the risk of HIV transmission to her baby.
They found that before 1997, when potent anti-HIV therapy became available, the first-born twin did have an increased risk of becoming infected with HIV. They think that this is because the first-born twin was being exposed to more HIV in the birth canal.
However, once the use of potent anti-HIV drugs became standard, the risk of HIV transmission in cases of twin pregnancies disappeared. The researchers think that this is because potent HIV treatment is more likely to reduce viral load to undetectable levels.
PML - A rare opportunistic infection that is still with us
Since potent anti-HIV treatment became available there has been a dramatic fall in the number of AIDS-defining opportunistic infections and cancers seen in people with HIV. This is because HIV treatment allows the immune system to strengthen, meaning that infections and cancers don’t have the ‘opportunity’ to develop.
Progressive multifocal leukoencephalopathy (PML) is a rare AIDS-defining illness that affects the central nervous system. It is caused by the JC virus and destroys the sheath that surrounds nerves. Before potent anti-HIV treatment became available, survival in HIV-positive people who developed PML was very poor, typically less than six months. However, better survival has been seen if treatment is provided using a protease inhibitor and the antiviral drug cidofovir.
Researchers at a recent conference were told that PML is still a concern for HIV-positive people, even when potent HIV treatment is available. The disease can develop when a person has a CD4 cell count of around 200. Late diagnosis of HIV, or late commencement of HIV treatment could allow the JC virus to get into the brain and increase the risk of PML developing.
It is also possible that some of the cases of PML being seen today are immune reconstitution illnesses. These happen when the recovering immune system has an excessive response to existing infections that weren’t causing illness.
Side-effects
Drugs from the NRTI class of antiretrovirals, particularly AZT and d4T (stavudine), can damage the mitochondria, the part of human cells which are essential for the production and transportation of energy.
So-called mitochondrial toxicity is responsible for a number of side-effects associated with HIV drugs, particularly lactic acidosis, peripheral neuropathy and body fat changes.
Doctors now avoid using AZT and d4T, the drugs most associated with mitochondrial toxicity, whenever they can.
But the latest research suggests that a person’s genetics can also increase their risks of experience mitochondrial toxicity. Japanese and Thai researchers found that a genetic mutation was associated with the side-effect.