World AIDS Day
There are always a lot of HIV-related statistics released in the period around World AIDS Day which is this Friday, December 1st.
I have very mixed feelings about World AIDS Day. On the one hand, it focuses the media spotlight on HIV, and is used by many HIV organisations as an opportunity to raise some much-needed cash. I’m sure that it also prompts some people to think about their own risk of HIV or their attitudes towards the virus and the people who are infected with it.
But on the other hand, much of the media coverage that World AIDS Day generates is just plain bad – cliché-ridden hand wringing about the scale of the global epidemic or “failure of the safer sex message to get through” without any real analysis of what is driving the continued spread of HIV, or what HIV prevention methods work.
Media coverage of World AIDS Day often trivialises or ignores the everyday difficulties or complexities involved in living with HIV.
And poor reporting and understanding of what living with HIV involves can have serious consequences: the UK government’s independent Expert Advisory Group on AIDS last week commented on draft guidelines for the criminal prosecution of HIV and other sexually transmitted infections, suggesting that they “lack a real understanding of the very different concerns, circumstances and vulnerabilities of people living with HIV”.
Let’s hope that these comments are noted.
HIV and sexual health in the UK and beyond
In the run up to World AIDS Day on December 1st, the UK Health Protection Agency and UNAIDS published their annual updates about the state of the HIV epidemic at home and abroad.
The UK now has one of the fastest growing HIV epidemics in Europe, with approximately 7,500 new infections reported for 2005 so far. Most of these new infections (2,760) were the result of heterosexual sex in Africa, a fall on the year before, and there were 2,356 new infections amongst gay men, a slight rise on 2004. Approximately 33% of people newly diagnosed with HIV had their infection diagnosed when their CD4 cell count was below 200. UK treatment guidelines state that HIV treatment should be started if CD4 cell count is at this level or below as it indicates that there is a real risk of potentially life-threatening infections or cancers.
Statistics also showed that people with HIV in the UK were more likely to be diagnosed with certain sexually transmitted infections (STIs). Three quarters of all cases of LGV and around 45% of cases of syphilis involved HIV-positive gay men.
Worldwide, it is estimated that there were 2.6 million new HIV infections in 2005, bringing the global total to 39.5 million. Eastern Europe and Central Asia have the fastest growing epidemics, but 66% of all the world’s HIV infections are in sub-Saharan Africa. A million people in this region were receiving HIV treatment in June of this year – a quarter of those who needed it.
Criminalisation of HIV transmission
There have been eleven prosecutions using the criminal law for the sexual transmission of HIV in the UK. The Crown Prosecution Service in England and Wales recently conducted a public consultation exercise on prosecutions for the reckless transmission of HIV and other sexually transmitted infections.
National HIV organisations have been united in their opposition to the criminalisation of the reckless transmission of HIV. Last week the Department of Health’s independent Expert Advisory Group of AIDS condemned the prosecutions and the CPS’s guidelines as “damaging”, and added that prosecutions were “having a negative impact on public health, because such a policy is a major barrier to normalising the disease.”
Mother-to-child transmission of HIV
A mother can pass on HIV to her baby in the womb, during delivery, or by breastfeeding. But the risk of this happening can be reduced to less than 1% by the use of anti-HIV drugs during pregnancy , having a caesarean delivery or an actively-managed delivery if viral load is low enough, and by not breastfeeding.
It’s important that a woman is aware that she has HIV so that she can be provided with the appropriate care to prevent her passing on HIV to her baby. All pregnant women in the UK are routinely offered HIV tests as part of their ante-natal care.
Figures from a hospital in east London, however, show that many women were not being diagnosed with HIV until late in their pregnancy, meaning that there was less time for HIV treatment to suppress viral load to undetectable levels before delivery. Indeed, ten women (14% of the study population) had a viral over 1000 – which is considered to be the level where there is a real risk of mother-to-child transmission and 47% had a viral load over 50.
The doctors think that many women delayed coming forward for medical care because they were worried about their entitlement to free NHS care.
Resistance and darunavir
HIV can become resistant to the drugs that are used to treat it. Resistance to one anti-HIV drug can mean that resistance develops to other, similar drugs.
Researchers have been working to develop new drugs which it is harder for HIV to become resistant to, or work against resistant virus. One of these drugs is the protease inhibitor, darunavir , the safety and effectiveness of which is currently being studied in clinical trials.
Doctors have found that few people with resistance to the currently available protease inhibitors have resistance to darunavir. Research has also shown that using darunavir with the fusion inhibitor T-20 (enfuvirtide, Fuzeon), produced good results even in people with “medium level” resistance to darunavir.
Tenofovir and the kidneys
The anti-HIV drug, tenofovir (Viread), is processed by the body using the kidneys. Soon after tenofovir was approved, reports emerged that it was causing kidney problems in a small number of patients. When researchers looked at these reports in more detail, they found that tenofovir was no more likely to cause kidney problems than some other HIV drugs, and that when such problems did occur, they tended to happen in people who had existing kidney problems.
Doctors have now spent a lot of time looking at the effect of tenofovir on the kidneys, and at a recent conference eleven separate studies looked at this issue. Overall, these studies confirmed what is already known – that approximately 4% of people who start treatment with tenofovir experience kidney problems; these problems are usually mild; and they go away when treatment with tenofovir is stopped.
The studies revealed that two people taking tenofovir died because of kidney failure. But both patients had a pre-existing history of kidney problems.
Some of the studies also revealed that tenofovir can cause bone problems.
It is recommended that everybody who is HIV-positive, particularly if they are taking anti-HIV treatment, should have the health of their kidneys checked at regular intervals.
Hepatitis C treatment
Hepatitis C is a virus that affects the liver, causing illness and death in the long term. Because HIV and hepatitis C are transmitted in similar ways, many people with HIV also have hepatitis C (this is called HIV/hepatitis C coinfection). Although treatment for hepatitis C is available, it does not have a high success rate in people who have HIV.
Doctors have been looking to see if they can improve the effectiveness of anti-hepatitis C treatment in people with HIV. One strategy they have tried with good results is to lengthen the duration of hepatitis C treatment, and another is to dose the anti-hepatitis C drug, ribavirin, according to a person’s weight.
A Spanish study provided patients with a daily dose of 1000mg of ribavirin if they weighed 75kg or less, or a dose of 1200mg a day if they weighed more than 75kg. This was combined with weekly injections of pegylated interferon.
Treatment was provided for a year, and 50% of patients were assessed as having a treatment response – higher than that seen in studies using standard doses of ribavirin.
The success of anti-hepatitis C treatment is, in part, determined by what strain or genotype of hepatitis C a person is infected with. Genotypes 1 and 4 are the hardest to treat. A sustained response to treatment was seen in 36% of people with these genotypes in the study – again this is higher than the level of treatment response seen in studies using standard ribavirin doses.