Grey areas
For me, having HIV means living with uncertainty. Few things about life with HIV are black and white. Rather there are many, many grey areas. These grey areas are present in medical, social, economic, personal, and ethical aspects of life with HIV. This was illustrated by much of the news on aidsmap.com this week which showed how we still need clear answers about some fundamental aspects of HIV. For example:
- How long will anti-HIV therapy keep me alive for?
- When is the best time to start HIV treatment?
- How should resistance tests be used?
- What’s the best way to use treatment for hepatitis C in people with HIV?
What are the right and responsibilities of people with HIV and their healthcare workers regarding the criminalisation of HIV transmission?
Life-expectancy
Potent anti-HIV therapy has transformed the prognosis (outlook) of people with HIV who have access to it.
Without treatment, HIV will gradually cause damage to the immune system leading, in most people with HIV, to severe illness and death within ten to 13 years of infection.
The arrival of potent, effective HIV treatment in the mid-1990s transformed the prognosis of people with HIV. The number of new AIDS diagnoses and HIV-related deaths in the UK has fallen from a high of around 1,500 just before effective therapy for HIV became available to around 200 – 400 today. Most of the deaths in people with HIV are now either because a person was diagnosed so late they could not be treated effectively, or are due to factors not directly related to HIV.
Effective HIV treatment has been around for a little over ten years. New drugs, or new formulations of drugs, mean that its becoming more powerful, easier to take, and more tolerable all the time.
But effective HIV therapy hasn’t been around long enough to say exactly how long a person who is taking it can expect to live.
Researchers have therefore used mathematical models to predict how long HIV treatment will work and what the life expectancy of somebody with HIV in a country like the UK would be.
A new Danish study predicts that a person diagnosed with HIV in their early adult life and treated with potent HIV therapy could expect to live until they were 64. This is about ten years less than the life-expectancy for somebody who is HIV-negative.
HIV-positive people who are coinfected with hepatitis C virus had a shorter life expectancy, as did people who were diagnosed with HIV when they were older than 50.
Starting HIV treatment
More studies have been published about starting anti-HIV treatment. It’s quite a hot topic at the moment.
It is currently recommended that everybody who is ill because of HIV should start anti-HIV therapy. It is also recommended that people who have a CD4 cell count between 250 – 200 cells/mm3 should commence treatment with a potent combination of anti-HIV drugs. This is because a CD4 cell count at this level indicates that there is a very real risk of developing a potentially life-threatening infection in the near future.
But some doctors now think that HIV treatment should be started earlier – when a person has a CD4 cell count of 350 cells/mm3.
More evidence has been published suggesting that this may be a good idea.
Researchers in France have found that gay men choose to start HIV treatment earlier than other groups with HIV and that this leads to a better increase in their CD4 cell count with HIV treatment. The researchers noted that 50% of gay men started HIV treatment with a CD4 cell count above 350 cells/mm3, compared to only 36% of heterosexuals and 34% of injecting drug users.
Another study suggests that doctors and patients should look at CD4 cell counts and CD4 cell percentages when decisions are being made about starting HIV treatment. A CD4 cell percentage of 40% is considered “normal” and a CD4 cell percentage of 20% (equivalent of a CD4 cell count of 200 cells/mm3) or below shows that a person has a very real risk of becoming ill due to HIV. In a study involving almost 2,000 people who were starting HIV treatment, a team of American researchers found that a person’s CD4 cell percentage at the time they started HIV therapy was a significant predictor of the risk of HIV disease progression.
They found that people with similar CD4 cell counts but different CD4 cell percentages had significantly different risks of experiencing disease progression. For example, a person with a CD4 cell count of 240 cells/mm3, and a CD4 cell percentage of 9% had a 65% greater risk of progressing to AIDS or death than a person with the same CD4 cell count, but a CD4 cell percentage of 24%.
In addition, the researchers found that people with a higher CD4 cell count, but a low CD4 cell percentage were more at risk of becoming ill due to HIV than people with a lower CD4 cell count and a higher CD4 cell percentage. For example, a person whose CD4 cell count was 350 cells/mm3, but whose CD4 cell percentage was 14%, was more likely to experience HIV disease progression than a person whose CD4 cell count was 200 cells/mm3 and whose CD4 cell percentage was 24%.
They write, “thus, there may be persons with an absolute CD4 cell levels above 200 cells/mm3 who could derive greater benefit from the earlier initiation of HIV therapy than do others.”
Resistance tests
About 15% of people in the UK have primary HIV resistance – that’s to say they were infected with HIV that was resistant to at least one antiretroviral drug.
Because of this, UK HIV treatment guidelines recommend that everybody should have a test to check for HIV that is resistant to anti-HIV drugs before starting anti-HIV therapy. The results of this test allow doctors to select the drugs which will have the most effect against a person’s HIV.
The usefulness of resistance testing in people who have been infected with HIV for over a year has been questioned. This is because resistant virus isn’t as able to reproduce as HIV that is antiretroviral drugs work against. This means that the drug-sensitive virus becomes dominant and isn’t readily picked up by resistant tests. The resistant virus is still present in small quantities, however, and reemerge when anti-HIV drugs are used.
An American study has shown that resistant testing is useful even if you its not known how long a person has had HIV. The study was conducted in 2005 and involved 103 people who had HIV for an unknown period of time. Resistance tests found that 25% had drug resistant HIV.
The researchers think that the resistance was caused by the transmission of drug resistant virus; the failure of PEP treatment to prevent infection with HIV; and even people sharing anti-HIV drugs.
HIV and hepatitis C
HIV and hepatitis C virus are transmitted in similar ways and many people who have HIV also have hepatitis C. This is often called HIV/hepatitis C virus coinfection. Liver disease caused by hepatitis C is now a major cause of illness and death amongst people with HIV.
Treatment is available for hepatitis C virus, but it works less well in people with HIV than in those who are only infected with hepatitis C.
It is currently recommended that people with HIV and hepatitis C should be treated with a combination of pegylated interferon and ribavirin.
The study involved gay men who are thought to have been infected with hepatitis C via sex.
A total of 61% of people had a sustained response to treatment that consisted of pegylated interferon alone. The researchers found that adding in ribavirin did not improve the effectiveness of treatment, but did increase the risks that a person would experience side-effects.
“Our data…suggest that pegylated-interferon monotherapy in the setting of acute hepatitis C infection may be as effective as pegylated-interferon/ribavirin combination therapy, and at the same time less toxic”, conclude the German researchers. But they add, “future trials are needed to investigate into this matter.”
HIV and the law
Another conviction for the reckless transmission of HIV
A 35 year-old man became the tenth person in the UK to be convicted for the reckless transmission of HIV. The man had unprotected sex with his girl friend without telling her that he had HIV. He was sentenced to three and a half years in prison and the judge ordered that he be deported to his country of origin – Zimbabwe – on his release from jail.
It is understood that one of the man’s healthcare workers contacted the woman because of concerns that the man was exposing her to HIV. The Department of Health recently conducted a consultation exercise about the responsibilities of healthcare workers in situations such as this.