HIV update - 30th August 2017

What is “successful ageing” for people living with HIV?

When Canadian researchers interviewed HIV-positive people over the age of 50 and asked how they would define “successful ageing”, six key themes emerged:

• Accepting limitations – the interviewees talked about the importance of coming to terms with the realities of ageing and of not expecting to be able to have the same level of activity as when they were younger.

• Staying positive – for example, one man said, “Having a sunny disposition on life, don’t let things drive you down, don’t sweat the small stuff. That’s a big one. Don’t sweat the small stuff.”

• Maintaining social support – remaining connected with friends, family and other people with HIV was recognised as an essential element of successful ageing.

• Taking responsibility – being involved in managing one’s own healthcare. One interviewee said, “We’re dealing with HIV and it’s not going to go away, so we have to be self-reliant and we have to be good managers of our health and our psyche so that we don’t fall into the doldrums.”

• Healthy lifestyle – eating healthily, abstaining from drugs and smoking, getting rest and sleeping well, minimising stress and regular exercise.

• Engaging in meaningful activities – these could be maintaining existing activities or finding new ones, including taking care of oneself, taking care of other people, volunteering or employment.

The researchers say that while healthcare professionals’ models of successful ageing tend to emphasise physical health and the absence of disease, their interviewees were less concerned about this – only one person mentioned living to an old age – and were much more concerned about the psychological and social aspects of getting older. As the interviewees felt it was particularly important to remain in control of their lives as they got older, doctors should take care to understand the goals and priorities of each of their patients.

Generic drugs just as effective as branded medications

A new study of 440 people switched to generic antiretroviral drugs at an Italian clinic and a matched group of patients who remained on their branded medication has found no evidence of generic drugs being less effective or causing more side-effects.

In many countries, health services are under increasing financial pressures. At the same time, the patents on several antiretroviral drugs have expired and cheaper, generic versions of the same drugs have been made available. Doctors and pharmacists are expected to use generic drugs when possible as they generally work as well as branded drugs, and the money saved can pay for other treatments and services. 

This is one of the first studies done which compares outcomes between people prescribed branded and generic drugs. It followed 440 people who were stable on branded lamivudine (Epivir), zidovudine/lamivudine (Combivir) or efavirenz (Sustiva) and were switched to a generic version of the same drug. The researchers compared outcomes for this group with a matched cohort of patients at the same clinic who did not switch drugs.

With an average of 15 months of follow-up for each patient, the researchers found that treatment failure (viral load becoming detectable) occurred less often in people taking generic medicines. There was no difference in the rate of viral blips and in time spent with low levels of detectable viral load between the two groups. And the numbers of people stopping or changing their treatment – usually because of side-effects – were the same in people taking generic and branded drugs.

The researchers concluded that they could find no evidence of generic anti-HIV drugs being less effective or having more side-effects.

To find out more about generic medicines, read NAM’s booklet ‘Taking your HIV treatment’.

Steep drop in HIV diagnoses in New South Wales

Australia’s most populous state, New South Wales, has reported a steep drop in HIV diagnoses in gay men. In the year from July 2016 to June 2017 there were 217 diagnoses, compared with an average of 289 in the previous five years, a decrease of 25%. The drop was even steeper if we look only at diagnoses in the first half of 2017 (a decrease of 31%) or at recently acquired infections (a decrease of 40%).

The quarterly figures for HIV diagnoses reported in 2017 are the lowest since records began in 1985. This is despite a notable increase in the number of people getting tested for HIV.

The data suggest that New South Wales’ ambitious policy which aims to virtually eliminate HIV transmission by 2020 is having an impact. The strategy combines a scale-up of HIV testing, immediate treatment when people are diagnosed and a large pre-exposure prophylaxis (PrEP) study. It also includes education campaigns about the impact of HIV treatment on transmission which have had a significant impact on gay men’s understanding of this issue.

The policy is having an impact on gay men and other men who have sex with men. In contrast, diagnoses in heterosexual men and women are not falling. And people born overseas, including men who have sex with men, have not seen a decrease in diagnoses.

Professor David Cooper, Director of the Kirby Institute that is running New South Wales’ PrEP study, commented: “The rapid rate of decline in HIV diagnoses…is unprecedented internationally, and can be attributed to a high uptake of a combination of HIV prevention strategies and in particular to the rapid scale-up of targeted PrEP implementation.”

The menopause in women with HIV and hepatitis C

Menopause is associated with accelerated liver fibrosis in women with HIV and hepatitis C co-infection, an American study shows. Liver damage due to fibrosis – the build-up of scar tissue in the liver – begins to speed up as the menopause takes place.

In general, women have slower rates of liver fibrosis than men. This is thought to be due to hormonal differences, with oestrogen having protective effects in women. However, levels of oestrogen decline during and following the menopause.

The researchers followed 405 women with HIV/hepatitis C co-infection, collecting data for an average of nine years each; most women went through the menopause during this time.

They found that liver fibrosis rates increased as women transitioned through the menopause. They say that this means that women who are going through or have completed the menopause should be prioritised for treatment with modern anti-hepatitis drugs to avoid further liver damage.

To find out more about hepatitis C, read NAM’s booklet ‘HIV & hepatitis’. To find out more about the menopause, read NAM’s factsheet ‘Menopause and HIV’.

Non-alcoholic fatty liver disease

Liver disease is a major cause of ill health in people living with HIV. While it is most often caused by infection with hepatitis B or hepatitis C, liver disease is not always caused by a viral infection. Heavy alcohol consumption may be the cause. And scientists are paying more attention to another form of liver disease that can affect people with HIV, known as non-alcoholic fatty liver disease (NAFLD).

NAFLD is an umbrella term for a range of liver conditions affecting people who do not drink heavily. As the name implies, the main characteristic of NAFLD is that there is a build-up of excess fat in the liver. Studies in the general population show that NAFLD is linked to being overweight or obese; having insulin resistance or high levels of glucose in the blood (both associated with type 2 diabetes); and high levels of fats, particularly triglycerides, in the blood.

There are four stages to NAFLD:

1. Steatosis, also known as simple fatty liver – fat accumulates in the liver cells without any inflammation or scarring. Many people have steatosis without it causing any harm or progressing to the other stages.

2. Non-alcoholic steatohepatitis (NASH) – a more aggressive form where there is inflammation in and around the fatty liver cells. This may cause swelling and discomfort.

3. Fibrosis – where persistent inflammation causes scar tissue around the liver, but it is still able to function normally.

4. Cirrhosis – the most severe stage, where the liver becomes scarred and lumpy. It can lead to liver failure and liver cancer.

Several recent studies have been done on NAFLD in people living with HIV. One review found that as many as around one third of people with HIV may have NAFLD – a higher rate than seen in the general population.

At the recent International AIDS Society conference (IAS 2017) in Paris, researchers reported that having type 2 diabetes increased the risk of steatosis tenfold and being obese increased the risk elevenfold. Having metabolic syndrome (at least three factors that are associated with an increased risk of heart disease, including obesity, high blood pressure, abnormal levels of cholesterol, raised triglycerides and high blood glucose) raised the risk fourfold. Longer use of HIV treatment (especially older drugs such as zidovudine and stavudine) was also associated with steatosis.

At the same conference, another group of researchers reported that people with HIV with metabolic syndrome were about twice as likely to have at least stage F2 fibrosis, about four times more likely to have at least stage F3 fibrosis and about eight times more likely to have cirrhosis. Those with obesity were about three times more likely to have stage F2 or F3 fibrosis and about four times more likely to have cirrhosis. 

Finally, a small study shows that in people with steatosis, switching anti-HIV drugs from efavirenz (which may be associated with fatty liver) to raltegravir leads to significant decreases in the degree of fatty liver disease.

Maintaining a healthy weight through eating a well-balanced diet and taking regular exercise is the best way to prevent NAFLD. There isn't currently any medication that can treat the condition, but various medicines can be useful in managing the problems associated with the condition. For example, your doctor may recommend medication to treat high blood pressure, high cholesterol or type 2 diabetes.