HIV update - 27th September 2017

Smokers more likely to die of lung cancer than AIDS

People living with HIV on antiretroviral treatment with an undetectable viral load who smoke are much more likely to die of lung cancer than HIV-related causes, according to the findings of an American modelling study.

The study suggests that smokers taking effective HIV treatment are between six and thirteen times more likely to die of lung cancer than of an AIDS-related illness. Moreover, 10% of all people with HIV who are linked to care will eventually die of lung cancer.

The modelling study lends further weight to the view that smoking poses a greater threat to the health of people with well-controlled HIV disease than the virus itself. Smoking reduces life expectancy through cardiovascular disease (stroke and heart attack), cancers and chronic obstructive pulmonary disease (emphysema). Around 40% of people living with HIV in the United States smoke, compared to around 15% of the general population.

The study shows the benefits of stopping smoking. For example, 23% of men who smoke around 16 cigarettes a day are estimated to die of lung cancer. But if the same men quit smoking by the age of 40, just 6% would die of lung cancer.

The researchers advise doctors to work harder to help people with HIV quit. Smoking cessation interventions, including nicotine replacement therapies such as varenicline and bupropion, should be a key part of the package of care for people with HIV, they say.

To find out more, read NAM’s factsheets ‘Smoking’ and ‘Lung cancer’.

Controversy over pregnancy guidelines

Women should be offered the choice to avoid treatment with tenofovir and emtricitabine during pregnancy owing to a higher risk of stillbirth and early infant death associated with these drugs, according to recommendations in the British Medical Journal (BMJ).

However, this runs contrary to guidelines from several organisations, including the British HIV Association (BHIVA) and the World Health Organization. BHIVA has issued a statement, explaining why it disagrees with the BMJ’s recommendations.

Current BHIVA guidelines recommend HIV treatment for everyone living with HIV, including pregnant women. Women who are already taking HIV treatment when they become pregnant should continue with the drugs they are already taking. Pregnant women starting HIV treatment can usually follow the same BHIVA guidelines as for other people – these guidelines recommend tenofovir and emtricitabine as a first choice, to be taken along with a third drug. Tenofovir and emtricitabine are included in the combination pills Truvada, Atripla, Eviplera and Stribild.

All of the different sets of recommendations have been put together by expert clinicians, who have looked at thorough reviews of the available scientific evidence, taking into account all the relevant studies that were available at the time. But different experts can sometimes have different interpretations of the same evidence.

They can also have different priorities. One important feature of the BMJ’s review was that they took particular note of women’s values and preferences regarding HIV treatment during pregnancy. This suggested that it was very important to women to avoid stillbirth and early infant death. Avoiding HIV transmission was very important to women, but so was their babies being healthy in other ways. Their recommendations took into account all of these concerns.

While the BMJ reviewers looked at several studies, one was particularly influential. This was called PROMISE and was conducted in six African countries and in India. It included a comparison of pregnant women with HIV taking either:

• Tenofovir/emtricitabine and lopinavir/ritonavir, or
• Zidovudine/lamivudine and lopinavir/ritonavir.

Both drug regimens were equally effective in preventing HIV from being passed on to the infant. Problems including premature birth, stillbirth and infant death within a week of birth were not common, but did occur at a higher rate in women taking the tenofovir/emtricitabine regimen.

This is the reason why the authors in the BMJ recommend that women should be offered the choice to avoid tenofovir and emtricitabine. They suggest zidovudine and lamivudine as an alternative. These are older drugs, also known as AZT and 3TC, which are often provided together in a single pill.

However, the doctors at BHIVA take a different view. They say that the PROMISE findings are less relevant to the UK because all these participants took lopinavir/ritonavir, drugs which are no longer recommended in BHIVA guidelines. An interaction between lopinavir/ritonavir and tenofovir might make problems more likely.

Further, BHIVA notes that the PROMISE findings relate to pregnant women taking HIV treatment for the first time. In contrast, most women living with HIV in the UK are already taking treatment when they get pregnant.

BHIVA also points to several reviews and observational studies showing that tenofovir and emtricitabine are safe in pregnancy. This included a very large study from Botswana, which found that tenofovir/emtricitabine was safer than zidovudine/lamivudine, and that the highest risk of adverse outcomes was in women taking lopinavir/ritonavir.

All this information is complex and can be confusing. One thing that both sets of experts – those at the BMJ and those at BHIVA – agree on is that doctors must take the time to talk with their patients and to fully involve them in treatment decisions. Women should be informed of all the potential benefits and harms of treatment options, they say.

There’s more information in NAM’s booklet ‘HIV & women’. NAM's online tool ‘HIV & pregnancy’ can give you personalised information about your options.

People with HIV not getting all the health checks they need

The majority of HIV-positive people in the UK are not receiving recommended monitoring of their heart disease risk – and many other important tests are being missed – according to the results of an audit conducted by the British HIV Association (BHIVA).

Heart, liver, kidney and bone disease are now important causes of illness in people living with HIV. Having these conditions identified without delay is important so that the right treatment can be started.

BHIVA set guidelines for routine monitoring of adults living with HIV in 2011. During 2015 they contacted 123 clinics in the UK to check whether the guidelines were being followed.

Some guidelines were widely followed. Everyone taking HIV treatment should have their viral load tested at least every six months, and this was the case for 90% of people. Staff should assess adherence to treatment at least once a year, and this happened for 93% of people. Most people had blood tests for hepatitis B and C.

But the audit highlighted some problems:

• People with HIV should have their risk of heart disease and other cardiovascular problems assessed every three years, but this only happened for 45% of people, even in those over the age of 50.

• Doctors should ask all patients about whether they smoke at least every two years, but there was only evidence of this for 66% of people. (And only 45% of smokers were offered smoking cessation services.)

• Everyone should have a sexual health screen at least once a year (more often for some people), but this had only happened for 66% of people.

• All women with HIV should have cervical screening each year, but this was only provided for 53% of women, with a further 22% advised to go to their GP or a sexual health clinic for it.

• Everyone over the age of 50 should have their risk of a bone fracture assessed every three years, but this was only done for 17% of people in this age group. Measurements of bone mineral density for the over-70s were similarly low. 

BHIVA says that one problem might be confusion among HIV doctors about what they should be providing, and what GP surgeries should be doing. “Improved communication between HIV and primary care services would streamline and improve care,” they say.

To find out more about the tests you need, read NAM’s simple illustrated leaflet ‘Health checks’ or the more detailed booklet ‘CD4, viral load & other tests’.

Marathon training safe

An endurance exercise programme that helped 13 HIV-positive people prepare for a marathon was safe, German researchers have recently reported.

The reason this is of interest is that little is known about the effects of sporting activities on the health of people with HIV. Studies involving people in the general population have shown that regular endurance training can be associated with short-term minor immune suppression and increased frequency of colds and coughs – but also long-term boosts in immune function.

The researchers monitored 12 men and one woman who completed a year-long training programme and took part in a marathon in 2010. Most of them were doing well on HIV treatment but several had been ill in the past. Participants trained three to four times a week, with 3-4 hours of running at the beginning, increasing to 7-10 hours per week. By the end, participants were training to 70-80% of their maximum heart rate.

By the end of the training programme, participants’ average CD4 count had increased from 640 to 745. There were improvements in cholesterol and blood pressure.

The researchers say the main finding was that the programme was safe and caused no harm, such as an increase in infections. The boost in immune function shown by the increased CD4 count was another positive finding.

To find out more, read NAM’s factsheet ‘Exercise’.

More HIV diagnoses among the over-50s

Just over one in six people diagnosed with HIV in Europe over the last decade was over 50 years of age, according to an analysis from 31 countries.

Although the rate of new diagnoses in older people is less than a quarter of the rate in people under 50, the rate of diagnosis in older people is on the increase in half the countries surveyed. These include Belgium, Germany, Ireland and the United Kingdom.

Older people are more likely than younger people to be diagnosed at a late stage, with a low CD4 count and advanced HIV disease. (Thirty-nine per cent of people over 50 had a CD4 cell count below 350 cells/mm³.) Older people with new diagnoses are more likely than younger people to be heterosexual.

The researchers say that healthcare workers need to be more proactive in offering HIV testing to older people, especially when they have health problems which could be caused by HIV.