HIV treatment – starting treatment
If treatment guidelines were changed to recommend that people start HIV treatment when their CD4 cell count is around 500, it would mean that 50% of HIV-positive people would need to start treatment within a year of their infection with HIV, a European study has shown.
UK and European guidelines currently recommend that HIV therapy should be started when a person’s CD4 cell count is around 350.
But some doctors think it would be better if patients started treatment earlier, when their CD4 cell count is in the region of 500. In the United States, the guidelines recommend treatment is started at 500.
The advantages of earlier treatment may include a reduced risk of HIV-related illnesses and non-HIV-related illnesses, such as cardiovascular disease and some cancers. In addition, early treatment may be a way of controlling the epidemic, as successful therapy significantly reduces potential infectiousness.
But earlier treatment would have cost implications and healthcare budgets around the world, the UK included, are under considerable pressure.
For this study, doctors looked at the records of over 18,000 people. The approximate date they became infected with HIV was known.
They found that if the CD4 cell threshold for starting treatment were increased to 500 then almost 50% of people would need to start treatment within a year of their infection with HIV.
This compared to about a quarter of people needing to start therapy within twelve months if the CD4 threshold was 350, and 9% if the threshold was 200.
Starting HIV treatment – recovery of the immune system
Older age is associated with poorer recovery of the immune system after starting HIV treatment, a French study shows.
Another factor connected with a weaker improvement in CD4 cell count was a strong immune response to the infection cytomegalovirus (CMV).
Most people experience an increase in their CD4 cell count after they start HIV treatment. But this isn’t always the case.
It’s already known that the functioning of the immune system deteriorates with age. In addition, a strong response to viral infections can have an impact on the immune system.
In this recent study, researchers in Paris showed that older people (those aged over 65) had a poorer CD4 cell increase after starting HIV treatment than younger people.
CMV is very common, but in people with a reasonably strong immune system it doesn’t tend to cause any problems. It can cause serious illness if a person has a very low CD4 cell count.
But the researchers also found that a strong immune response to the infection was associated with lower increases in CD4 cell count after initiating HIV therapy. This was especially the case for older people.
The researchers believe their findings are “important for the long-term clinical management of the aging HIV-infected population.”
Early HIV treatment is especially recommended for older people in current UK guidelines.
For more on ageing and HIV, including features, news and news from other sources, visit our ageing and HIV topics page.
HIV treatment – factors associated with starting treatment
People are more likely to start HIV treatment if they think it will benefit their health, and that they will be able to take it properly, a study conducted among poorer US patients shows. Readiness to start was also an important factor.
With the right treatment and care, many people with HIV will be able to live a long and healthy life. Treatment also has an important role in HIV prevention.
But many people who would potentially benefit from treatment are not taking anti-HIV drugs.
One group with low levels of treatment uptake in the US is the urban poor, who often have limited access to health care and live with multiple social, economic and health problems.
Researchers recruited 88 HIV-positive people from a poorer area of San Francisco. None were taking HIV treatment, even though they had a CD4 cell count below 500 – the US threshold for starting therapy.
They completed a questionnaire, which asked about their expectations of HIV treatment, their readiness to start treatment, and their confidence that they’d be able to adhere to dosing schedules.
One year later, 60% of the study participants had started treatment. There was no difference in the CD4 cell counts of the people who started treatment and those who didn’t, at the time they started treatment.
However, people who thought they would benefit from treatment were much more likely to start taking anti-HIV drugs, as were those who thought they’d be able to adhere properly and people who believed they were ready to start therapy.
The investigators conclude that improving treatment uptake “is particularly important given the personal benefit and potential reduced risk of transmission that appear to accompany early treatment of HIV.”
HIV gene therapy – progress towards a cure
A functional cure for HIV would consist of a treatment intervention that could stop or control HIV replication without the need for lifelong treatment, even though HIV was not eliminated from the body.
SB-728-T is a one-off treatment that genetically edits CD4 cells, making them less vulnerable to infection with HIV.
The therapy was investigated in nine patients who were taking HIV therapy. Despite having an undetectable viral load, their CD4 cell count remained low. Treatment with SB-728-T led to an increase in CD4 cell count, and genetically modified cells were found in both the blood and in gut mucosa – an important ‘reservoir’ for HIV.
A second small study involved six patients. They interrupted their HIV treatment for twelve weeks after being treated with SB-728-T.
Viral load remained undetectable in one patient after receiving SB-728-T therapy.
Research into the therapy will continue.
Our publication HIV treatment update recently featured an article about HIV gene therapy written by one of the trial participants.
HIV treatment and children – avoid crushing Kaletra tablets
Using crushed Kaletra (lopinavir/ritonavir) tablets leads to reduced levels of the drug in the blood of HIV-positive children, US research shows.
Kaletra, a boosted protease inhibitor, is available in a paediatric tablet containing 100mg lopinavir and 25mg ritonavir.
However, some children have difficulty swallowing tablets, and crushing or breaking the tablets can make them easier to take.
But researchers found that children treated with crushed Kaletra had levels of the drug in their blood reduced by up to 40%. This could mean that HIV treatment fails to suppress viral load, possibly leading to resistance.
The researchers conclude: “Increased doses and therapeutic drug monitoring are needed to ensure adequate lopinavir/ritonavir exposure in patients requiring crushed Kaletra tablets. The reduced exposure with crushed Kaletra tablet dosing reinforces the need to discourage this dosing practice.”
Correction to last week’s story: Viral load and infectiousness
Last week we reported on a US study showing that some HIV-negative gay men based safer sex decisions on knowledge of their HIV-positive partner’s viral load.
We mistakenly said the rate of disclosure for HIV-positive MSM who disclosed to their partners was 7%; this figure actually referred to the proportion of men who disclosed they had HIV in answering the survey.
There was also a numerical error in the original news story; this has now been corrected.