HIV treatment in children and young people
Many doctors think that HIV treatment could mean that a person with HIV has the chance to live a near-normal lifespan and to stay healthy for longer.
However, HIV treatments – like all drugs – do have side-effects. Some anti-HIV drugs have been linked to changes in body shape – where people have gained or lost fat in different areas of their body. They are also connected to some metabolic (chemical) changes in the body, such as increased cholesterol and glucose (blood fat and blood sugar).
AZT (zidovudine, Retrovir) and d4T (stavudine, Zerit) are the main drugs that cause these side-effects, which are also known as lipodystrophy. But we now know that protease inhibitors can also cause metabolic changes in some people and that long-term HIV treatment could increase the risk of heart (cardiovascular) disease.
Because of these body-shape changes, which can be severe and distressing for people – doctors don’t usually recommend AZT and d4T to people starting treatment now. But people who were infected with HIV at birth and have already been on HIV treatment for some years will often have been on these drugs at some point.
Researchers in the US have found that children and young adults in that situation have lower levels of ‘limb fat’ than HIV-negative people the same age. They also found that they had higher total and LDL cholesterol levels, lower HDL cholesterol and higher insulin levels.
People infected at birth face taking HIV treatment for the rest of their lives and this research suggests that they should take special care to reduce the risk of heart disease. Lifestyle changes such as a healthy diet, taking regular exercise and not smoking benefit everyone’s health, and are particularly important for people with HIV. HIV clinics can help people look at their lifestyle and work out how best to reduce the risk of heart disease.Having a baby
With good medical care, HIV-positive women can give birth to healthy children without passing on HIV. But researchers in Thailand have found that HIV-positive pregnant women with a weak immune system are at higher risk of having a baby with a very low birth weight.
This condition, known as intrauterine growth retardation, generally means a baby is born weighing less than 2.5 kg, and is at increased risk of a number of serious conditions and of death. In resource-limited countries, this may be caused by a mother having poor nutrition or suffering from malaria. In richer countries such as the UK, smoking is a common cause of intrauterine growth retardation.
The good news is that the researchers believe that if women who are pregnant take combination HIV treatment once their CD4 count falls below 200 cells/mm3, not only will their health improve, it will help avoid passing on HIV to their baby and reduce the risk of a low birth weight. In the UK, treatment guidelines recommend people start treatment at 350 cells/mm3.
HIV-positive women who have regular check-ups with their HIV clinic will be able to discuss the best time to start treatment. Your doctor will also discuss with you the best treatment to take if you are pregnant or planning to have a baby – and your clinic can also help you with other health issues that are important if that’s the case, such as nutrition and help with stopping smoking.
HIV treatment and immune suppression
The aim of successful HIV treatment is an undetectable viral load.
Usually, as people’s viral load goes down, their CD4 cell count increases, which means that their immune system is becoming stronger.
Most people’s immune system recovers completely once they start HIV treatment. Researchers from two studies have found that some people on treatment do not reach normal CD4 cell count levels – although their viral load is undetectable and even after they have been on treatment for up to ten years.
It’s not clear what this might mean for people’s health in the longer term. But most of the people in this situation had started treatment with a CD4 cell count of under 200 cells/mm3. This research does confirm that there is a link between starting treatment late (with a low CD4 count) and the immune system not recovering as well. It is not yet clear what this might mean for those people, but there is some evidence that they might be more likely to experience AIDS-related illnesses and some unrelated conditions such as heart disease and cancer.
In the UK, doctors generally use CD4 cell counts to decide with patients when they should start treatment. Evidence has suggested that people who start treatment after their CD4 count falls to below 200 cells/mm3 are more likely to become ill or die. Because of this knowledge, last year, American, European and British treatment guidelines were changed to recommend that treatment should start when people’s CD4 cell counts are around 350 cells/mm3. You can discuss the right time for you to start treatment with your HIV doctor or other people at your HIV clinic.
Resistance
As we explained in last week’s HIV Weekly, HIV changes, or mutates, very slightly every time it reproduces. If HIV is able to reproduce when a person is taking anti-HIV drugs, then it can mutate to become resistant to these drugs.
This is why it’s very importance to take your HIV treatment properly and to get and keep your viral load to undetectable levels. It is possible to pass on a strain of HIV that is already resistant to certain drugs and will limit the treatment choices of people who become infected with it.
Researchers in France have found the rate of drug-resistant HIV being transmitted did not increase in the ten years between 1996 and 2006. They suggest that it has remained stable because of the introduction of effective HIV treatment. Eleven per cent of the people studied were resistant to at least one anti-HIV drug, and only two per cent were resistant to two or three types of drugs.
The only class of drug where resistance increased was the non-nucleoside reverse transcriptase inhibitors (NNRTIs). The number of people in France on treatment increased significantly in this period, but not because of transmitted resistance.
The researchers say these results confirm that resistance tests should be done when someone is diagnosed or when they are about to start treatment. British treatment guidelines recommend regular resistance testing.
HIV and TB
World TB Day (24 March) marked the fact that many people worldwide still miss out on tuberculosis (TB) treatment and die from the disease. A key issue in addressing TB is tackling co-infection with HIV and TB.
About one quarter of deaths in people with HIV were caused by TB in 2007, the World Health Organization (WHO) has announced. HIV-positive people in countries with high HIV prevalence are around 20 times more likely to develop TB than those without HIV.
Internationally, the development of drug-resistant TB makes diagnosis and treatment more complicated and the condition harder to cure. But there is encouraging news for TB treatment from recent research done in two South African clinics, showing that treatment with isoniazid, the main anti-TB drug, together with HIV treatment, reduces the risk of people developing active TB by 90%.
TB is the most common AIDS-defining illness in the UK, but treatment is available for it in nearly every case.A new service for Londoners with HIV
Here at NAM we know the important role written information plays in supporting people living with HIV to take decisions about their treatment and care.
Evidence suggests that the more people are involved in decisions about their treatment, the better their health and wellbeing.
Since 1987 NAM has specialised in providing written information, such as these email newsletters, patient information booklets, HIV Treatment Update, and online resources like our websites, aidsmap.com and NAMlife.org.
Sometimes, though, there’s nothing that can beat a face-to-face discussion.
Now, across the capital, there is a new free service providing just that: the HIV Health Support Service.
NAM has teamed up with the Terrence Higgins Trust to offer free one-to-one information and advice sessions about any aspect of HIV treatment and health. A Health Trainer is now available, near you, to offer you face-to-face, telephone or online support to help you improve your health and to live well with HIV.
Perhaps there are questions you have always wanted to ask your healthcare team but didn’t get the chance to? Or treatment and health issues you have never quite understood? Or maybe there have been topics you have read about in HTU you would like to know more about? Or services you would like to use but don’t know how? If so, a Health Trainer can help.
The HIV Health Support Service can be reached via THT Direct. Please call 0845 12 21 200 and ask to see a health trainer. Alternatively, you can use the online service at www.tht.org.uk/askthetrainer.