HIV update - 18th November 2015

Blood not needed for sexual hepatitis C transmission

There is scientific uncertainty about how hepatitis C is passed on during sex, but until now it has been assumed that transmission usually involves some contact with blood. For example, as anal sex may cause small abrasions and tears to the lining of the anus, leaving tiny traces of blood that you might not notice, this was thought to explain hepatitis C transmission during anal sex without a condom. 

But a new study shows that hepatitis C is sometimes present on the lining of the rectum. This means that the virus could be passed on even when there is no bleeding. The findings also help explain how fisting and sharing sex toys, especially in a group sex situation, can result in hepatitis C being passed on.

Swabs were taken from the lining of the rectum (around 7cm beyond the anal passage) of 45 men who had HIV and hepatitis C co-infection. Samples with traces of blood were excluded.

Hepatitis C was detectable in infectious quantities in half the specimens. Levels were lower than in blood samples, but men with high hepatitis C viral loads in blood were more likely to have detectable rectal samples.

There’s more information about how hepatitis C can be passed on during sex in an illustrated leaflet from NAM.

Poorer results for women

Women have triple the rate of poor treatment outcomes than gay men, a new study from the Royal Free Hospital in London shows.

One year after starting treatment, 20% of women had a detectable viral load (a possible indicator of treatment failure), compared to 6% of gay men. Whereas few gay men stopped taking their treatment for several days or weeks at a time, around one in seven women had done so.

A second UK study found that all the differences in results between women and gay men could be explained by social problems and different rates of depression.

Women were much more likely to report socio-economic problems. For example, 54% of women only sometimes or never had enough money for their basic needs (compared to 20% of gay men). But while 6% of people who always had enough money had a detectable viral load, this was the case for 15% of those who never had enough money.

Similarly, 17% of women were homeless, were sleeping on a friend’s sofa or had some other form of unstable housing (compared to 6% of gay men). While 17% of people with unstable housing had a detectable viral load, 5% of homeowners did.

The researchers say that better services are needed for women, to help them overcome these kind of social difficulties. This would help women maintain adherence to treatment and avoid treatment interruptions.

Low-level viral load

The studies on women described above used a single viral load above 200 copies/ml as an indicator of a poor response to HIV treatment. Repeatedly having a high viral load definitely raises the risk of illness, but does a low viral load between 200 and 500 copies/ml really matter?

Another study suggests that it does increase the risk of serious illness, although this remained a rare event overall.

The study includes over 7000 people taking HIV treatment in Italy and looked at viral load six months after starting treatment. The researchers wanted to see who went on to have an AIDS-related illness or to die from any cause during the study.

• In people with an undetectable viral load, 5 people in every 1000 went on to have AIDS or to die.
• In people with a viral load between 50 and 200 copies/ml, 12 people in every 1000 went on to have AIDS or to die.
• In people with a viral load between 200 and 500 copies/ml, 19 people in every 1000 went on to have AIDS or to die.

But these low-level viral loads did not make any difference to rates of serious illnesses that are not described as ‘AIDS’ including heart, liver and kidney disease.

When people have a detectable but low viral load, it’s possible that the low level of ongoing viral replication can lead to increased activation and inflammation of the immune system. This may contribute to the higher rate of illnesses seen.

Hormonal contraception is safe

A new study provides reassurance that hormonal contraceptives are safe for women living with HIV to use.

Hormonal contraceptives include pills, injections and implants which provide hormones. Non-hormonal contraceptives include condoms and intrauterine devices (IUDs).

The study was done because some researchers have been concerned that hormonal contraceptives may affect the immune system’s response to HIV, possibly worsening the impact HIV has on the body.

Looking at a group of 1656 women living with HIV in Zambia, women who used contraceptive injections or implants had a much lower risk of death than other women. Women who used oral contraceptive pills had a similar risk as women who used non-hormonal contraceptives. Women who used implants had a slower fall in their CD4 cell count than other women.

So overall, women taking hormonal contraceptives were in better health than other women.

When considering contraception, it’s important for women taking HIV treatment to check that there are not any drug interactions between their treatment and their contraception. To get personalised information, you can use NAM’s interactive, online tool HIV & contraception.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a disease that makes it hard to breathe. ‘Chronic’ indicates that it is a disease that people have on an ongoing basis. Rates of COPD are higher in people living with HIV than in other groups, for reasons that are unclear.

Chronic obstructive pulmonary disease can cause coughing that produces large amounts of mucus, wheezing, shortness of breath, chest tightness, and other symptoms. Cigarette smoking is the main cause of COPD but long-term exposure to other lung irritants (like air pollution, chemical fumes, or dust) can also cause it.

A new study looks into what raises the risk of COPD symptoms suddenly getting worse, usually for several days at a time. It looks at this both for people living with HIV and for people who don’t have HIV.

Overall, people with HIV had a greater risk of worsening symptoms than people who don’t have HIV. Having a low CD4 count or a detectable viral load raised this risk.

As expected, two of the most important factors that raised the risk of worsening symptoms were continuing to smoke and heavy alcohol drinking. Moreover, these factors were even more important for HIV-positive people than HIV-negative people.

The study suggests that HIV-positive people who have COPD can reduce symptoms by stopping smoking, taking HIV treatment and cutting down on alcohol.