HIV update - 29th October 2014

Important news on PrEP

In the last two weeks, two separate studies of Truvada as pre-exposure prohylaxis (PrEP) have found that it is highly effective in reducing the risk of HIV infection for HIV-negative gay men. Both studies have announced their results much earlier than planned, because the evidence of effectiveness came much sooner than had been anticipated.

These dramatic results give new impetus for PrEP to be made available to gay men in the UK and elsewhere in Europe. So far it has only been offered to men taking part in the research trials.

The PROUD study recruited around 500 men in England. Half were offered PrEP immediately and half were asked to wait one year. On Thursday October 16, its researchers announced that all men in the study will now be able to take PrEP.

The IPERGAY study involved around 400 men in France and Canada. Half were given PrEP and half were given a dummy pill (a placebo). Yesterday, its researchers also announced that all its participants will now be given a tablet that really does contain Truvada.

Men in the English study were asked to take a tablet every day. Those in the French study were told that they only needed to take it before and after sex – a dose in the 24 hours before anticipated sex, and then, if sex happened, two separate doses in each of the two days that followed.

In both studies, an analysis of the results – conducted ahead of schedule – found that the number of HIV infections in the group of men who had not been given PrEP was much higher than among those given PrEP. The differences were so clear and so large that it was felt that it would be unethical to continue to deny PrEP to the men in the comparison groups.

Nonetheless, precise figures will not be published until early next year. The researchers for both studies will also remain in contact with study participants in order to collect long-term data on several key issues – adherence, sexual behaviour and drug resistance. 

Professor Jean-François Delfraissy, director of the French HIV research agency the ANRS commented: "This is a major breakthrough in the fight against HIV. The results of the ANRS IPERGAY trial should change national and international recommendations for HIV prevention".

Diabetes

Diabetes is a condition where the amount of glucose in the body is too high because the body cannot use it properly. Diabetes exists in two forms: type 1, which usually occurs earlier in life; and type 2, which usually occurs as a person gets older.

People with HIV have a higher risk of type-2 diabetes than other people. The reasons for this are unclear, but could include the side-effects of some anti-HIV drugs. Another cause may be the ongoing response of the immune system (the body’s natural defence system) to HIV – this is known as chronic inflammation.

Researchers have now examined factors associated with type-2 diabetes in a cohort of around 3700 people who were taking HIV treatment. Each year, 8 in every 1000 people developed diabetes.

They found that people who had somewhat higher levels of two biological markers of inflammation were more likely to develop diabetes later on. (The two biological markers are called interleukin-6 and high sensitivity C-reactive protein.)

This supports the belief that inflammation (the immune system’s reaction to HIV) is an underlying factor in the development of diabetes in people living with HIV. Treatment with anti-HIV drugs reduces but cannot completely eliminate HIV-related inflammation (HIV-infected cells continue to produce small amounts of virus deep within the body). Finding additional ways to further reduce inflammation may help reduce the risk of diabetes and other health problems.

For more information, you may find our factsheet on diabetes helpful. In addition, Diabetes UK – in partnership with Metro – has recently started a monthly support group in north London for people living with HIV and diabetes. For more information contact london@diabetes.org.uk or call 020 7424 1116.

Which class of anti-HIV drug works best?

Standard treatment for people starting HIV treatment for the first time is a combination of three different drugs. Anti-HIV drugs belong to different classes depending on the way they work against HIV. The three most frequently used classes of anti-HIV drug are:

• nucleoside reverse transcriptase inhibitors (NRTIs, or ‘nukes’),
• non-nucleoside reverse transcriptase inhibitors (NNRTIs, or ‘non-nukes’), and
• ritonavir-boosted protease inhibitors (PIs).

Most HIV treatment guidelines recommend that it includes a two-drug ‘backbone’ from the NRTI class.

In addition, people may take an NNRTI, such as efavirenz (Sustiva, also included in the Atripla tablet), nevirapine (Viramune) or rilpivirine (Edurant, also included in the Eviplera tablet).

Alternatively they may take a ritonavir-boosted protease inhibitor, such as atazanavir (Reyataz), darunavir (Prezista) or lopinavir (in the Kaletra tablet), or a drug from the integrase inhibitor class, such as raltegravir (Isentress).

A new analysis compares the outcomes of almost 10,000 people taking either an NNRTI or a protease inhibitor. Each person was taking HIV treatment for the first time and was a participant in a randomised controlled trial. The data from all these trials were pooled and re-analysed.

The results are very reassuring – the two classes of drug worked equally well. Specifically there were no significant differences in terms of:

• The number of people with an undetectable viral load after one year.
• The amount by which CD4 cell counts rose.
• The number of people who changed treatment because of side-effects.
• The number of people who developed AIDS.
• The number of people who died.

However, more people taking an NNRTI did change treatment because they did not have an undetectable viral load.

For more information on starting HIV treatment, take a look at our factsheet, Starting HIV treatment. You might also find some of our online tools helpful, including Get set for HIV treatment.

Treatment for tuberculosis

Some cases of tuberculosis (TB) are very hard to treat, as the infectious bacteria is resistant to the drugs most commonly used to treat it. This is known as multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB).

Recently a new antibiotic, bedaquiline, became available. This drug is effective against drug-resistant strains of TB.

A new study from France has found that it was very effective, even better than had been seen in clinical trials. The researchers reviewed outcomes for 35 people who took the drug along with other anti-TB drugs. None of the participants were HIV-positive, half had hepatitis C and almost all were born outside France.

After six months, 97% of people who had TB in the lungs before taking the treatment no longer had signs of infection.

The results for side-effects and safety were satisfactory, although two people had to stop treatment because of a potentially dangerous disturbance in their heart rhythm.