HIV treatment – when to start treatment
There’s a lot of debate about the best time to start HIV treatment. Current European and British guidelines recommend that therapy should be started when a patient has a CD4 cell count of around 350.
However, US guidelines say that treatment should be started when a patient’s CD4 cell count is in the region of 500, and they don’t rule out starting treatment earlier.
The latest study to look at this question involved 21,000 patients in Europe and the US, who received care between 1996 and 2009. All had a baseline CD4 cell count above 500.
Results showed that patients who waited to start HIV therapy until their CD4 cell count fell below 350 were 38% more likely to develop AIDS than patients who started treatment when their CD4 cell count was around 500.
However, there was no evidence that starting treatment at 500 was associated with better overall survival – rates were similarly high for patients who started therapy at 350.
Non-HIV-related diseases such as heart, kidney and liver disease are now an important cause of serious illness in patients with HIV. Doctors think that starting treatment earlier will reduce the risk of these illnesses.
But this latest study didn’t gather information on the impact of therapy on these diseases.
Nevertheless, the investigators suggest: “If the goal is to prevent AIDS-defining illness or death, our findings support cART [combination antiretroviral therapy] initiation once the CD4 cell count decreases below 500 cells/mm3.”
HIV treatment – cardiovascular health
New Canadian research has linked several anti-HIV drugs, including abacavir (Ziagen; also in the combination pills Kivexa and Trizivir), with an increased risk of heart attack.
The research also showed that HIV-positive people were twice as likely to have a heart attack as HIV-negative individuals of the same age and sex.
In the study, treatment with abacavir, ritonavir (Norvir), lopinavir (Kaletra) and efavirenz (Sustiva; also in the combination pill Atripla), were all linked with an increased risk of heart attack.
However, the researchers emphasised that their findings need to be seen in the wider context of cardiovascular health. In particular, the risk associated with anti-HIV drugs was minimal when compared to traditional risk factors, such as smoking.
The design of the study also limited the robustness of its results.
It was an observational study, meaning that underlying differences in patients could have affected the findings.
HIV and diabetes
A lot of HIV treatment and care is now devoted to preventing and treating non-HIV-related illnesses, especially those associated with ageing – one of which is diabetes.
Because of this, researchers from the US Department of Veterans Affairs compared the quality of diabetes care provided to HIV-positive and HIV-negative patients.
Their analysis looked at seven key components of care such as haemoglobin and cholesterol levels, kidney function, blood pressure control and eye health.
The results showed that the care provided to patients with HIV was good, often excellent. Patients who went to larger clinics were especially likely to receive good quality care.
Overall, however, patients with HIV were less likely than HIV-negative individuals to have had key tests.
Outcomes, such as cholesterol and blood pressure control, were also slightly poorer for patients with HIV.
“Attention needs to be focused on the quality of general medical care for this population,” comment the investigators.
Screening for anal cancer
Rates of anal cancer are increased in patients with HIV, and separate research from the US Department of Veterans Affairs has shown that screening for pre-cancerous cell changes in routine HIV care is feasible and acceptable to patients.
Infection with some strains of human papillomavirus (HPV) can cause cell changes in the cervix and anus that can progress to cancer.
The earlier these changes are detected, the better the chance of successful treatment that can prevent the progression to cancer.
The introduction of cervical screening led to a dramatic fall in rates of cervical cancer.
However, even though rates of anal cancer are higher in patients with HIV, few patients are screened for pre-cancerous cell changes.
A total of 160 individuals were invited to participate in the research and 82% agreed.
Screening showed that 52% of patients had abnormal anal cells. This was associated with a lower CD4 cell count.
Results showed the value of screening regardless of a patient’s sexual history. Abnormal anal cells were detected in individuals who said they had never had anal sex.
“In our study abnormal anal cytology was as frequent in patients who denied anal intercourse as in patients with a history of anal intercourse,” comment the authors.
They add, “HIV-infected patients need to know they are at risk of anal cancer, and anal health should be an issue of priority for HIV care providers to discuss with their HIV-positive patients.”