HIV update - 28th February 2018

Depression and the outcomes of HIV treatment

People with HIV who spend more time living with depression have poorer engagement with care and have worse long-term outcomes, according to a new study.

The study included almost 6000 people being treated at eight American hospitals. The symptoms of depression were assessed every six months. The researchers then calculated the proportion of days a person had been depressed – for example, 50% of days in the last six months, or 75% of days in the last six months.

While a third of people in the study had no days with depression, the average was 14% of days with depression. Four per cent of people were depressed every day.

In the whole sample, around a fifth of scheduled appointments were missed. And for each 25% increase in the proportion of days with depression, there was an 8% increase in the risk of missing an appointment.

Around a fifth of viral load measurements were above the limit of detection, indicating treatment that was not fully effective, possibly because of difficulties with adherence. Again, people with depressive symptoms were a little more likely to have a detectable viral load – for each 25% increase in the proportion of days with depression, there was a 5% increase in the risk of this.

There were 158 deaths during the study. Each 25% increase in depression was linked with a 19% increased risk of death.

“Even modest increases in the proportion of time spent with depression led to clinically meaningful increases in negative outcomes,” sum up the researchers. They say that the implication of their study is that doctors should pay more attention to depression in their patients and offer treatment when people have it. This should mean people spend less time depressed and their HIV is better managed.

For more information, read ‘Depression’ in NAM’s booklet ‘HIV, mental health & emotional wellbeing’.

HPV and anal cancer

Nine in ten cases of anal cancer are linked to human papillomavirus (HPV), a very common infection that can be passed on during sex. HPV is not a single virus – there are about 150 types of HPV that have different effects.

Some types of HPV don’t seem to do any harm, other types cause anal and genital warts, while others can cause anal and cervical cancer. New research has given a better understanding of which HPV types are more likely to cause anal cancer.

The researchers pooled the results of 95 studies which included over 18,000 people. This showed that HPV16 is the type of HPV which is most strongly linked with cancer. Among men with HIV, HPV16 was present in:

• 26% of men who had no anal lesions
• 37% of men who had low-grade anal lesions that don’t seem to be linked to cancer
• 51% of men who had high-grade lesions that are associated with a small risk of developing cancer in the future
• 67% of men who had anal cancer.

There wasn’t such a clear pattern for other types of HPV.

But a third of anal cancers in HIV-positive people did not involve HPV16. The researchers reviewed the different vaccines that are available to see what proportion of anal cancer cases they might be able to prevent. Some vaccines protect against more HPV types than others.

The first generation of HPV vaccines only worked against HPV16 and HPV 18. Infection with these two types represents 74% of cases of anal cancer in people with HIV.

Currently the NHS uses vaccines which work against HPV6 and HPV11 as well as HPV16 and HPV18. These vaccines are helpful in preventing genital and anal warts but don’t make much difference to anal cancer – they could protect against 77% of cases.

There is a newer vaccine, not yet available on the NHS, which works against nine HPV types: 6, 11, 16, 18, 31, 33, 45, 52 and 58. These HPV types represent 92% of cases of anal cancer in people with HIV.

The younger you are, the more likely you are to benefit from vaccination. UK guidelines recommend that the following groups of people living with HIV receive the HPV vaccine: women up to the age of 40, gay men up to the age of 40, and heterosexual men up to the age of 26.

For more information, read NAM’s factsheet ‘Anal cancer and HIV’.

Long-term impact of hepatitis C treatment

Untreated hepatitis C can cause serious liver disease, including fibrosis (a build-up of fibrous scar tissue, leading to a ‘stiff’ liver) and cirrhosis (serious scarring that blocks blood flow through the liver, kills liver cells and interferes with liver function). The more advanced the fibrosis and cirrhosis, the greater the risk of serious illness and death.

Successful hepatitis C treatment can clear the virus from the body. But less is known about its long-term impact on fibrosis or cirrhosis.

A new study sheds light on this, using data on 269 Swedish people who all had advanced fibrosis (stage F3) or cirrhosis (stage F4) before they were treated. They all took the now obsolete treatment based on interferon injections and had achieved a sustained virological response. The researchers collected follow-up data on participants an average of eight years after they were treated, with some followed for 15 years.

At that time, most had seen a significant improvement – this was the case for 87% of those who had had advanced fibrosis and 83% of those with cirrhosis. Liver stiffness improved gradually over several years, with those people who had completed treatment longer ago having better results.

However, the situation did not improve for a minority of people. At the time of follow-up, 24% still had advanced fibrosis. People more likely to have a poor outcome had had cirrhosis (more severe scarring) before treatment, were over the age of 55 before treatment or had been overweight. Losing weight before treatment may be advisable.

Despite the poor results for a minority, the study shows the positive, long-term impact of hepatitis C treatment for most people who had had severe liver damage. Treatment allows the liver to heal and previous damage to be reversed.

NHS England has also recently announced that it is working to negotiate deals with drug companies to further lower the cost of hepatitis C treatment. While the cost of modern hepatitis C drugs was extremely high when they were first introduced, the prices actually paid by the NHS have come down and the treatments are now easier to get hold of.

The NHS aims to eliminate hepatitis C by the year 2025. To achieve this, NHS England plans to increase the number of people treated for hepatitis C to 13,000 a year. But it will also need to deal with the problem that around 100,000 people may need treatment but aren’t in contact with clinical services. Some have never been diagnosed. Others were diagnosed at a time when treatments weren’t so good, decided not to take it and dropped out of care.

For more information, read NAM’s booklet ‘HIV & hepatitis’.

HIV treatment and conception

The benefits of HIV treatment for pregnant women living with HIV and their babies are clear, including an extremely low risk of mother-to-child HIV transmission. These benefits far outweigh any possible risks to the infant due to exposure to anti-HIV drugs.

Nonetheless, there are still some uncertainties about conception, in particular whether it's best to start HIV treatment before trying for a baby. It’s also unclear whether some anti-HIV drugs are associated with a higher risk of adverse birth outcomes than others.

Researchers in the Netherlands looked at data on 1392 babies born to HIV-positive mothers between 1997 and 2015. In 550 cases, the mother had been taking HIV treatment before becoming pregnant.

The researchers were particularly interested in babies who were born with a low birth weight. A smaller baby will need extra care during the early months of life and is more likely to have health problems in later life.

They found that the proportion of low-birth-weight infants born to HIV-positive mothers (24%) was much higher than in those born to HIV-negative African mothers in the Netherlands (2%). When the mother was taking HIV treatment before pregnancy, the rate was a little higher (27%) than when she started treatment during pregnancy (22%). The researchers did a statistical analysis which took into account other differences between the two groups of mothers, especially those which could influence birth outcomes, and still found this difference.

It appeared that there were more likely to be problems when the mother had taken anti-HIV drugs from the protease inhibitor class, compared to other types of anti-HIV drugs. But the researchers stress that other studies on the same issue have come to different conclusions. More research will be needed before advice on the safest anti-HIV drugs to use during conception can be given.

For more information, read ‘Pregnancy and birth’ in NAM’s booklet ‘HIV & women’.

High blood pressure

Blood pressure is the pressure of blood in your arteries – the vessels that carry blood from your heart to your brain and the rest of your body. If blood pressure is too high (also called hypertension), it causes a strain on the walls of your arteries and on your heart. Having high blood pressure greatly increases your risk of having a heart attack or stroke, and can make diabetes or kidney disease worse.

Four in ten Americans living with HIV have high blood pressure, according to a new study. This is higher than the three-in-ten figure for the general population of the United States.

In fact, the number of people with high blood pressure might be higher. In this study, people with two blood pressure readings above 140/90 were considered to have high blood pressure. Since the research was done, new American guidelines have adjusted the figures, so that anyone with readings above 130/80 is considered to have high blood pressure. This means that more people are now considered to need medication to lower their blood pressure. (In the UK, 140/90 is still the cut off used to define high blood pressure.)

Men, older people, black people and individuals with a poor response to HIV treatment were more likely to have high blood pressure.

Medicines may be prescribed to help control blood pressure. These include diuretics, beta-blockers and ACE inhibitors. But in the American study, only half of those with high blood pressure were having it effectively controlled with treatment. One in seven were undiagnosed and untreated.

The researchers think that doctors are missing opportunities to diagnose and treat high blood pressure, especially in younger people and those with poor access to healthcare in the US.

For more information, read NAM’s factsheet ‘High blood pressure’.