HIV update - 4th July 2018

Suicide in people with HIV

Two studies have recently been published on suicide in people with HIV. To put this into context, we reported last year that Public Health England had found that suicide accounted for 2% of deaths in people with HIV. In men living with HIV, the rate of suicide was twice that of the general population. In women living with HIV, it was the same as in the general population.

Now French researchers have looked at the same issue. They found that approximately 5% of deaths in people with HIV were due to suicide, over three times the rate in the general population of France.

Whereas the numbers of suicides in people with HIV went down during the 1990s as medical treatments improved, they found that the rate does not seem to have changed since the early 2000s.

To better understand the circumstances that may have contributed to people’s suicides, the researchers compared data on 70 people with HIV who took their own lives and a comparison group of 279 people living with HIV who did not.

They found that suicide was associated with mental health problems and other factors that were not directly related to HIV. On the other hand, HIV-related factors – such as a low CD4 cell count, having been diagnosed with AIDS, or viral load – were not associated with an increased risk of suicide. There were also no differences in the rates of suicide between gay and straight people in this predominantly male cohort.

Among people with HIV, suicide was more frequent in people who lived alone, did not have children, used drugs, had alcohol problems, had had a previous suicide attempt, suffered from depression or had taken medicines used to treat depression, anxiety or other mental health difficulties.

These are similar to the factors which are associated with suicide in the general population. The researchers say that interventions to reduce the risk of suicide should be prioritised for people who have mental health difficulties – as they are in people who don’t have HIV.

The second recent study on suicide relates to the anti-HIV drug efavirenz (also contained in the Atripla combination pill). Until recently, efavirenz was one of the most widely used anti-HIV drugs, but it is starting to be used less often because of its side-effects such as dizziness and unusual dreams. A few studies have also found an increased risk of suicide or suicidal thoughts in people taking efavirenz, but most have not.

Researchers in Uganda looked at the number of people who had suicidal thoughts, comparing people taking efavirenz and people taking nevirapine, an anti-HIV drug from the same drug class. Before people started to take treatment, 7% reported suicidal thoughts and one-third had symptoms of depression.

People were followed for around two years. In this time, the number of people reporting suicidal thoughts appeared to be lower in those taking efavirenz, although the difference was not statistically significant (in other words, could have been due to chance). Moreover, depression was observed less often in those taking efavirenz than nevirapine.

The results are reassuring, especially for people of African descent. As there can be genetic differences which affect the way drugs are processed in the body and their side-effects, it is useful for this issue to be researched in an African population.

For more information, read ‘Mental health problems’ and ‘HIV treatment side-effects and mental health’ in NAM’s booklet, ‘HIV, mental health & emotional wellbeing’.

Rilpivirine and efavirenz

Rilpivirine and efavirenz are two medicines from the class of drugs known as non-nucleoside reverse transcriptase inhibitors (NNRTIs). Italian doctors have published a study comparing results in people taking the two drugs.

Rilpivirine is marketed under the brand name Edurant and is also available in a combination tablet with emtricitabine and tenofovir disoproxil (Eviplera) and in a combination tablet with emtricitabine and tenofovir alafenamide (Odefsey). Efavirenz was originally marketed under the brand name Sustiva, but generic versions are now available. It is also available in a combination tablet with emtricitabine and tenofovir disoproxil (Atripla).

The researchers compared outcomes in 1490 people taking HIV treatment for the first time that contained either rilpivirine or efavirenz. Four in five participants were male. It’s worth noting that the choice of drug was not determined by randomisation (chance) and there were some differences in the profiles of the groups of people taking each drug. This means that some of the differences in outcomes could be due to something other than the drugs.

The researchers found that both drugs were highly effective in reducing viral load to an undetectable level (the aim of treatment). Two years after starting treatment, 99.7% and 96.3% of people given rilpivirine and efavirenz respectively had a viral load below 50 copies/ml.

However, people treated with efavirenz were significantly more likely than people taking rilpivirine to change their drugs. In the efavirenz group, 24% changed their medication, compared to 10% in the rilpivirine group. The problems in efavirenz users were most often side-effects like dizziness or disturbed sleep, but there were also a few more cases of raised cholesterol and abnormal liver results.

The results suggest that rilpivirine is easier to tolerate than efavirenz but just as effective when used as first-line treatment.

For more information, see NAM’s factsheets about rilpivirine, Eviplera, Odefsey, efavirenz and Atripla.

Diabetes in women

Diabetes isn't adequately managed in American women who have both HIV and type 2 diabetes, according to a new study. Over a fifteen-year period, the proportion keeping their HIV under control more than doubled, but only a minority achieved key markers for control of type 2 diabetes.

In the United States, people who have diabetes are encouraged to meet targets known as ABC. These goals are important because people with diabetes are at increased risk of cardiovascular disease.

• A stands for A1C, the blood test that shows the average blood sugar level in recent months. It should be below 7%.
• B stands for blood pressure. It should be below 140/90 as having high blood pressure is a key risk factor in developing heart disease, stroke and other complications of diabetes.
• C stands for cholesterol. The level of low-density lipoprotein (LDL) cholesterol should be below 100mg/dL. High cholesterol also increases the risk of heart attacks and strokes.

In 2015, 58% of women achieved the A goal, 73% achieved the B goal and 53% achieved the C goal.

The proportion who achieved all three ABC goals at the same time was only 22%. And just 11% achieved the combined ABC goals and were non smokers.

These results are similar to those in women who don’t have HIV, but the researchers say that healthcare providers need to pay more attention to diabetes. They have helped women who have both HIV and diabetes to bring their HIV under better control, but not the diabetes.

For more information, read NAM’s factsheet ‘Type 2 diabetes and HIV’.