HIV update - 24th May 2017

Life expectancy is near normal for many people with HIV

Many newspapers have reported on a new study of life expectancy of people living with HIV who are taking HIV treatment. The study confirms what we have been reporting since 2010 – that many people living with HIV can expect to live as long as their peers who do not have HIV. People who start HIV treatment and achieve CD4 counts over 350 by the end of their first year of treatment have life expectancies approaching normal.

The improvement in survival for people with HIV is one of the great health success stories of recent times. Life expectancy has been transformed since the 1980s.

Researchers used data from 18 cohort studies in Europe and North America to track what happened to 88,504 people when they first started treatment for HIV. A key feature of the study is that the researchers compared people beginning HIV treatment in different time periods, beginning in 1996 and ending in 2010. They have been able to show that life expectancy substantially improved during these years.

Of note, the researchers only looked at mortality in the first three years of taking treatment, and used this information to estimate longer-term life expectancy. This makes the calculations of improvements over time more accurate.

But it does mean that the life expectancy of someone who began treatment in 1997 is only estimated on the basis of what happened to people of a similar profile between 1997 and 2000. The analysis doesn’t take into account the improvements in HIV treatment and care since then. These are likely to continue to benefit people who began treatment two decades ago and are still taking it today.

The key finding was that people who began HIV treatment between 2008 and 2010 and who were still alive with a CD4 count over 350 a year after starting treatment have estimated life expectancy approaching that of the general population. A 20-year old starting HIV treatment can expect to live to 78.

To add in some of the extra details and insights:

• Between 1996 and 2010, life expectancy increased by around ten years for both men and women.
• There is still an increased risk of death, compared to the general population, during the first year of treatment, when some people continue to have low CD4 cell counts. Most deaths occur during this first year. People who survive the first year have near-normal life expectancies.
• These are average figures and not everyone does so well. Life expectancy is poorer for people who inject drugs and people who begin treatment with a low CD4 count.
• Outcomes are better in Europe than in North America.
• Over the years there have been particularly large drops in deaths due to liver disease (including hepatitis C) and heart disease.
• The improvement in life expectancy over time isn’t only due to the direct effects of HIV treatment on viral load and CD4 count. It seems that better medical care for other conditions (like heart disease, diabetes and cancers) has also had an impact.

Protease inhibitors and viral load in semen

Protease inhibitors may not be the best class of drug for people newly diagnosed with HIV to start treatment with, if they wish to quickly reduce their risk of passing HIV on to others, according to a small randomised study.

Researchers recruited 36 gay men with HIV who were not yet taking HIV treatment. They all started first-line therapy containing tenofovir/emtricitabine (Truvada). They were randomly allocated to a third drug:

• darunavir (Prezista) boosted by ritonavir (a protease inhibitor),
• rilpivirine (Edurant, also in Eviplera/Complera, an integrase inhibitor), or
• elvitegravir boosted by cobicistat (Vitekta, more usually in Stribild, a non-nucleoside reverse transcriptase inhibitor).

While HIV was fully suppressed in semen within 12 weeks of starting therapy in participants taking rilpivirine or elvitegravir, in participants taking darunavir, a seminal viral load was still detectable in 42% of the participants. By 24 weeks, all but one participant had an undetectable viral load in semen.

The study appears to show that seminal viral load takes considerably longer to fall to undetectable levels in people taking darunavir – and maybe other protease inhibitors – than it does in people taking third drugs of the other two classes. This implies that people taking protease inhibitors may be infectious for longer.

Breathlessness, coughing and respiratory problems

People living with HIV have poorer respiratory health, even when they are taking effective HIV treatment, according to a small study.

Breathlessness, coughing and other symptoms of respiratory problems were compared between HIV-positive and HIV-negative people attending the HIV and sexual health clinics at the Royal Free Hospital, London. As the HIV-negative comparison group was recruited at sexual health clinics, the HIV-positive and HIV-negative groups had similar risk factors. In particular, rates of smoking and recreational drug use were similar between the two groups.

The 290 participants filled out questionnaires about symptoms that could be linked to conditions such as asthma, chronic obstructive pulmonary disease or bronchitis. Symptoms, especially breathlessness, were more common in those living with HIV, even though most were doing well on treatment with an undetectable viral load. People with HIV who had never smoked had more symptoms than the researchers expected.

The biological mechanisms driving this remain unclear. The researchers say that clinicians need to pay more attention to respiratory health in their patients. In particular, they should help people stop smoking.