HIV update - 18th October 2017

Big drops in HIV diagnoses in gay men in the UK

Official data from Public Health England confirms a number of previous reports – HIV diagnoses in gay men last year fell significantly for the first time throughout the UK since antiretroviral therapy started becoming available 20 years ago.

• Overall, in all social groups and all parts of the country, new HIV diagnoses fell by 18%.
• This was driven by a 29% drop in diagnoses in gay men in London.
• Elsewhere, there was an 11% drop in diagnoses in gay men in England.

“The UK is one of the first countries in Europe to witness a substantive decline in HIV diagnoses in gay and bisexual men,” says Public Health England. “Combination prevention is working: the decline is driven by large increases in HIV tests among gay and bisexual men attending sexual health clinics including repeat testing in higher risk men, as well as improvements in the uptake of antiretroviral therapy following HIV diagnosis. Other factors, including sustained high condom use with casual partners and internet access of pre-exposure prophylaxis (PrEP), will also have contributed to the downturn in HIV diagnoses in this group.”

Diagnoses among heterosexual men and women have been declining for several years, but mostly because of the impact of lower immigration from high-prevalence countries.

It is estimated that 86% of people living with HIV have been diagnosed; 96% of diagnosed people are taking HIV treatment; and 96% of treated people have an undetectable viral load. The UK is therefore close to meeting the United Nations’ targets to reach 90-90-90 on these indicators.

National AIDS Trust (NAT) said the results were proof that combining frequent testing, early treatment and PrEP can successfully reduce HIV. However, they pointed to groups who are missing out – progress for gay men is slower outside of London, similar reductions in diagnoses are not seen among heterosexual people, and black and minority ethnic people are more likely to be diagnosed with HIV late, with consequent poorer health outcomes.

“This is an unacceptable inequality which needs urgent attention,” NAT said. 

Single-tablet protease inhibitor regimen

Several single-tablet regimens are available, allowing people to take one pill a day for their HIV treatment. Until now, all were based on a drug from the non-nucleoside reverse transcriptase inhibitor (NNRTI) class or the integrase inhibitor class, along with a nucleoside backbone.

A new single-tablet regimen includes a protease inhibitor and a nucleoside backbone. This means that the tablet is based on a different drug class to other single-tablet regimens. The new pill may provide an additional option for people who need to change their treatment because of drug resistance.

Symtuza contains darunavir (the protease inhibitor) and cobicistat (a drug which boosts the effectiveness of darunavir) along with two drugs which form the nucleoside backbone: emtricitabine and tenofovir alafenamide (TAF, the newer version of tenofovir). Symtuza was approved by European regulators last month.

Results from a phase 3 randomised study of the new pill have recently been published. Those taking part were already taking a protease inhibitor-based treatment and had an undetectable viral load. Most were men in their forties who had been diagnosed with HIV for around ten years.

Half were randomly allocated to switch to the single pill, while the other half continued with their existing treatment. After a year, results were very similar in the two groups – 95% on the single pill and 94% on their existing treatment had an undetectable viral load.

Treatment was generally safe and well tolerated. Results on kidney and bone tests were generally more favourable in the Symtuza group compared to the group that stayed on their existing treatment, which is unsurprising as the single pill contains TAF, a version of tenofovir which is easier on the kidneys and bones.

To find out more, read NAM's booklet 'Anti-HIV drugs'.

Monoclonal antibody for people with multidrug-resistant HIV

Promising results from a small study have been presented for ibalizumab, a new type of drug for people who are not able to maintain an undetectable viral load with existing treatments, have drug resistance to several drug classes and have limited treatment options.

Ibalizumab belongs to a drug class known as monoclonal antibodies and works in a different way to existing antiretrovirals. Ibalizumab targets a protein on human cells rather than attacking HIV directly. It binds to the CD4 receptor on the surface of T-cells, but instead of preventing HIV from attaching to these cells, it blocks a shape change that is necessary for the virus to enter them.

The study enrolled 40 highly treatment-experienced people. They all took ibalizumab – as an intravenous infusion every two weeks – along with a selection of other anti-HIV drugs, selected for each patient on the basis of resistance testing.

After a year, participants had an average viral load reduction of at least 2.5 log₁₀. This is equivalent to a drop from 15,000 copies to 50 copies, or 250,000 copies to 750 copies. 

Ibalizumab was generally safe and well tolerated. The most common side-effects were diarrhoea, dizziness, nausea and rash. One person had to stop the study due to immune reconstitution inflammatory syndrome.

American regulators are expected to make a decision on ibalizumab in January.

Hepatitis C news

Several recent studies have reported on issues for people with HIV and hepatitis C co-infection:

• Despite clinical guidelines recommending hepatitis C treatment for almost everyone with the condition, around half of European countries restrict access to modern hepatitis C drugs, only allowing people with significant liver fibrosis to be treated. A fifth of countries impose restrictions on people with a history of heavy alcohol or drug use. This will make it harder to reach the World Health Organization’s goal of eliminating hepatitis C as a public health problem.

• Over a third of HIV-positive gay men suffer significant liver fibrosis (stage F2 or higher) within three years of hepatitis C infection. Having HIV co-infection might make rapid progression of fibrosis more likely. There was a greater risk of fibrosis in older men, those with alcohol problems and men who had not responded to interferon-based therapy during acute infection.

• In people with HIV and hepatitis C co-infection, the risk of stroke is increased by 24% and the risk of heart attack is increased by 33%, compared to people with HIV alone. This is according to an analysis which pooled the results of four previous studies. It is possible that the immune system’s inflammatory response to HIV and hepatitis C together causes the problem.

• Drinking three or more cups of coffee a day halves the risk of death from any cause for people with HIV and hepatitis C co-infection, according to a French study. Coffee contains caffeine and polyphenols which appear to prevent damage to the liver.

To find out more, read NAM's booklet 'HIV & hepatitis'.