Resistance to dolutegravir
A drug called dolutegravir is one of the mostly widely used HIV medications today. It belongs to a family of drugs called integrase inhibitors and is included in the tablets Tivicay, Triumeq, Dovato and Juluca.
Dolutegravir is recommended in most international treatment guidelines because as well as having relatively few side effects, it is more potent than many other HIV medications. Treatment failure happens to fewer than 5% of people who take it. Even when it does not work, very few people develop resistance to the drug, which means that treatment failure does not limit their future treatment options.
But that doesn’t mean that dolutegravir resistance never happens. A new study looked in more detail at 599 people whose dolutegravir-based treatment stopped working. Of these, 36 people (6%) had some level of resistance against dolutegravir.
The researchers found that a few things made resistance more likely:
- Taking dolutegravir on its own, without any other drugs. This is called monotherapy and is not recommended in guidelines, but some people in the study still did it.
- Taking dolutegravir as dual therapy, in combination with lamivudine (available as Dovato). This dual therapy appears to be more vulnerable to resistance than dolutegravir combined with rilpivirine (Juluca).
- Having resistance to NRTIs (the backbone drugs usually combined with dolutegravir). When this happens, it can create a situation of an unintended monotherapy as the NRTIs are present but do not work.
These findings do not mean that all people in these situations will end up with resistance to dolutegravir. For example, dual therapy with Dovato is an approved treatment that works well for many people. But the study does suggest that when dolutegravir is included in a combination of three fully active drugs, resistance is very unusual.
The search for an HIV cure
So far, HIV has proved almost impossible to eradicate from the human body but several strategies are being explored to cure HIV. In our recently updated page, read about the four possible paths to cure.
We have also published a page about people who have been cured of HIV or appear able to control the virus without treatment.
Tuberculosis
As tuberculosis (TB) is a big concern for people living with HIV in African and Asian countries, TB studies are often done there. But that doesn’t mean that TB doesn’t also affect people living with HIV in western Europe, North America and Australasia.
Researchers recently asked whether people living with HIV in these countries are tested enough for TB. They also questioned whether more people should be given a few months’ course of TB drugs as a preventive measure.
They first looked at how many people had inactive or ‘latent’ TB. In this situation, people have the TB bacteria in their body, but their immune system is able to keep it under control. For as long as TB is latent, it is not causing disease, there are no symptoms and TB can’t be passed on to anyone else.
Pooling the results of 51 previously published studies, 12% of people living with HIV had latent TB. Prevalence has decreased over time, as more people take effective HIV treatment. This is probably because HIV treatment strengthens the immune system, giving it a better chance to eliminate TB. In these studies done in western Europe, North America and Australasia, migrants were more likely to have latent TB than other people – many people were born in countries where TB is more common.
A few studies looked at how many people who had latent TB went on to develop ‘active TB’ – in order words, TB disease, with symptoms. They looked at this according to whether people had taken what’s known as ‘TB preventive therapy’ – a few months’ course of one or two TB drugs which aims to kill off the TB bacteria for good.
Each year, among 1000 people who had latent TB and hadn’t taken TB preventive therapy, 65 developed active TB.
And among 1000 people who had latent TB and had taken TB preventive therapy, six people developed active TB.
The researchers say that HIV clinics need to do more to screen for TB and to provide TB preventive therapy. If resources are limited, they should prioritise people who were born in countries where TB is more common (such as countries in southern Africa), or have other risk factors for TB.
Bone loss, osteoporosis, and HIV
Rates of bone loss (osteopenia and osteoporosis) are higher in people living with HIV than in the general population. There is also evidence that bone problems might happen at a younger age.
You can reduce your risk of osteoporosis by making changes to your lifestyle, including getting plenty of exercise, and making sure you get enough calcium and vitamin D.
Find out more in our updated page on aidsmap.
Liver disease
People living with HIV should have regular blood tests to monitor liver function. Having a healthy liver is important to everybody, but it is particularly important for people with HIV. The liver plays a key role in breaking down and processing medicines used to treat HIV and other infections.
The most common tests check levels of enzymes in your liver. These include alanine aminotransferase (ALT) and aspartate aminotransferase (AST).
Doctors in Brighton, UK, recently looked at people in their HIV clinic who had abnormal test results on two separate occasions at least six months apart. A major cause of raised liver enzymes can be infection with hepatitis B or C, but effective treatments are making hepatitis C less common. The doctors wanted to look in particular at people whose liver problems had other causes.
One in five people receiving HIV care in Brighton had abnormal test results that were not explained by hepatitis B or C. They were offered extra tests and investigation, including with a machine called FibroScan. This uses echo vibration waves, similar to an ultrasound, to detect hardening or stiffening of the liver.
Of 274 people tested with FibroScan, 35 had fibrosis (some hardening and scarring of the liver) and 19 had cirrhosis (more severe scarring, which blocks blood flow through the liver).
Among those with fibrosis or cirrhosis:
- 46% had ‘metabolic syndrome’. This is when someone has several linked health problems such as diabetes, high levels of glucose in the blood, abnormal cholesterol levels, high blood pressure and having an accumulation of fat around the waist. These problems are linked to so-called ‘fatty liver disease’, especially in people who are overweight or obese.
- 44% drank alcohol at hazardous levels. Excessive drinking can cause liver disease.
- 56% had a history of treatment with at least one HIV medication known to cause liver problems. These antiretrovirals include stavudine (d4T), nevirapine and long-term use of efavirenz, but the most important was didanosine (ddI) – one of the early HIV medications which is no longer in use.
While people will not be able to change the HIV medications they took two decades ago, the researchers say that heavy drinking and poor metabolic health are risk factors that can be changed. People with HIV are recommended to protect their liver by drinking less alcohol, maintaining a healthy weight, exercising regularly and eating a healthy, balanced diet.
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