HIV treatment – US guidelines
HIV treatment is a fast-changing and complex area of medicine. National and international guidelines help doctors to ensure that they provide the best possible treatment and care to their patients.
Guidelines in the US have just been updated. While much of the recommended treatment remains the same, there were a number of key updates.
What treatment to take: the guidelines have several categories for treatment: ‘recommended’, ‘alternative’, ‘acceptable’ and ‘not recommended’.
The CCR5 inhibitor drug maraviroc (known by the trade name Selzentry in the US and Celsentri in Europe), taken with AZT/3TC (Combivir), has been added to the list of ‘acceptable’ combinations. Use of maraviroc with FTC/tenofovir (Truvada) or 3TC/abacavir (Epzicom in North America, Kivexa elsewhere) may also be acceptable, but the guidelines say that more information is needed on these combinations.
Treatment including the protease inhibitor saquinavir (Invirase) has been downgraded from ‘alternative’ to ‘acceptable’. This is because of concerns that the drug can cause an irregular heartbeat.
Health monitoring: the guidelines state that treatment should be considered to have failed when viral load increases to above 200 copies/ml.
The guidelines also state that CD4 cell count only needs to be monitored every six to twelve months for most patients taking successful HIV treatment.
People whose viral load becomes detectable when taking an integrase inhibitor such as raltegravir (Isentress) should have a test to see if they have resistance to this type of drug.
HIV and TB treatment: people with HIV and tuberculosis (TB) need specialist treatment and care. The guidelines recommend that patients with a CD4 cell count below 200 should start HIV therapy no more than two to four weeks after initiating TB treatment.
The interval between initiating TB treatment and anti-HIV drugs should be no more than two to eight weeks for people with a CD4 cell count between 200 and 500.
Within eight weeks, people with a CD4 cell count above 500 should start HIV treatment.
You can read more about the updates on our website or download the full US guidelines from the US Department of Health and Human Services here.
New UK HIV treatment guidelines will be published later this year. You can read more about how the UK and European guidelines are created in this interview with Prof. Brian Gazzard and Prof. Jens Lundgren.
HIV treatment – treatment breaks
Taking breaks from HIV treatment can cause long-term problems, new research shows.
Treatment breaks are not recommended. The large SMART treatment interruption study showed that they were associated with an increased risk of illness. But patients in the study were only monitored for about six months.
In this new study, Swiss researchers monitored changes in CD4 cell counts and rates of illness and death in approximately 2500 patients who took long-term HIV treatment between 1996 and 2008.
They found that people who interrupted their HIV treatment had poorer increases in their CD4 cell count than those who took therapy all the time.
Patients taking treatment breaks were less likely to have an increase in their CD4 cell count above 350 or 500.
Rates of HIV-related illness, AIDS and death were also higher among patients interrupting their treatment.
Taking a break from treatment for six or more months was especially harmful. Therefore the researchers recommend that any treatment interruption should be as short as possible.
The patients with the best results were those who were on effective treatment and stayed on it all the time.
Taking HIV treatment as prescribed is often called ‘adherence’ and is an important part of living well with HIV. You can read more about adherence in various resources on our website, or contact us for a copy of our booklet Adherence & resistance. If you are having problems taking your HIV treatment, it’s a good idea to talk to someone at your clinic about it – they should be able to support you.
HIV care – statin treatment
The statins atorvastatin (Lipitor) and rosuvastatin (Crestor) have the biggest impact on lipid levels in people with HIV, a new study shows.
High blood lipids (cholesterol and triglycerides) can increase the long-term risk of cardiovascular disease. There seems to be a higher incidence of elevated lipids amongst people with HIV. High lipids can often be managed with changes in diet and exercise, giving up smoking, and treatment with a type of drug called statins can also lower blood lipids.
A number of different statins are available. Therefore US researchers monitored the impact of three drugs – atorvastatin, pravastatin (Lipostat), and rosuvastatin – on the cholesterol and triglycerides of 700 HIV-positive patients.
They found atorvastatin and rosuvastatin had a bigger impact on lipids than pravastatin.
Traditionally, pravastatin has been the preferred statin for use in HIV-positive patients. This is because of its low risk of interactions with antiretrovirals. “However,” write the investigators, “our findings suggest that the lipid-lowering effectiveness of pravastatin was significantly less than that of rosuvastatin or atorvastatin.”
There was no difference in the rate of reported side-effects between the three drugs. Potentially serious changes in liver or kidney function were rare.
Sexual health – herpes
Good sexual health is important to everyone, especially people with HIV. If left untreated, sexually transmitted infections can cause unpleasant symptoms and, in some cases, serious health problems. In addition, an infection can increase the risk of HIV transmission.
A very common sexually transmitted infection is genital herpes.
This is usually caused by herpes simplex virus-2 (HSV-2).
Infection with genital herpes is life-long. The first outbreak of genital herpes caused by HSV-2 is usually the worst, but it can come back.
However, people in the study who had the infection for a long time frequently had potentially infectious levels of the virus present in their genitals (‘shedding’), or had disease caused by HSV-2.
Among people who had had genital herpes for ten or more years, shedding was detectable on 17% of days and lesions caused by the disease on 9% of days.
There’s no cure for HSV-2. However, treatment with aciclovir can reduce the frequency and severity of attacks of genital herpes.
Condoms can reduce the risk of transmission to sexual partners.
You can download a factsheet on herpes from our website. There's lots of information on sexual health and sexually transmitted infections in our patient information booklet HIV & sex. A new edition will be available shortly - contact us for more information.