HIV update - 5th July 2017

Explaining high rates of heart disease in people with HIV

A modelling study suggests that living with HIV substantially increases the lifetime risk of heart disease and stroke, even after taking into account the high rate of smoking in many groups of people living with HIV.

The researchers estimated the risk of heart attacks, strokes and other forms of heart disease in three populations:

• The general population of the United States.
• HIV-negative people who are at high risk of acquiring HIV and who have similar rates of smoking and alcohol use as HIV-positive people.
• HIV-positive people in the United States.

The rate of heart disease in the latter two groups was estimated by taking the rate in the general population and adjusting for known risk factors, such as smoking, cholesterol and glucose intolerance.

The model estimated that by the age of 60:

• 13% of men and 9% of women in the general population would have had heart disease.
• 15% of men and 10% of women in the group at risk of acquiring HIV would have had heart disease.
• 21% of men and 14% of women living with HIV would have had heart disease.

By the age of 80:

• 45% of men and 34% of women in the general population would have had heart disease.
• 50% of men and 30% of women in the group at risk of acquiring HIV would have had heart disease.
• 58% of men and 38% of women living with HIV would have had heart disease.

Including the second group in the analysis helps disentangle the effects of lifestyle factors (such as smoking) and HIV infection on the risk of heart disease in people living with HIV.

It suggests that while smoking contributes to heart disease in people with HIV, the impact of HIV itself is more substantial. HIV infection causes ongoing activation of the immune system (inflammation) and metabolic changes such as low levels of 'good' HDL cholesterol, all of which contribute to the development of heart disease.

The researchers call for more research into the use of statins (drugs to prevent heart disease) in people living with HIV. A large randomised clinical trial, REPRIEVE, is testing whether giving the statin pitavastatin to people on HIV treatment over the age of 40 will reduce the risk of heart attack, stroke and other major cardiovascular problems in people who don’t meet current criteria for statin treatment. The study is designed to last up to six years and should report its results by 2021.

For more information, read NAM’s factsheet ‘The heart’.

Hepatitis A outbreak in gay men in Europe

The ongoing outbreak of hepatitis A in Europe has affected almost 1500 people, mostly men who have sex with men, epidemiologists reported this week. Large numbers of cases have been reported in Spain, France, the United Kingdom, Portugal, Italy and Germany. Scientists say that the outbreak has probably not reached its peak yet.

One group of cases was first identified in the Netherlands, among men who had attended the same sex-on-premises venue during the EuroPride festival in Amsterdam, and has been linked to cases in several other countries.

Hepatitis A can be prevented by vaccination. Public health authorities are encouraging gay and bisexual men to seek vaccination at sexual health clinics. However, production problems have led to shortages of the vaccine in several European countries.

Hepatitis A is transmitted in faeces (shit) and can be transmitted through food or drink contaminated with faeces. It can be picked up through sexual contact, especially oral-anal sex (rimming). Fingers, hands or penises that come into contact with the anus and then the mouth can provide a route of transmission.

For more information, read ‘Hepatitis vaccinations’ and ‘Hepatitis A’ in NAM’s booklet ‘HIV and hepatitis’.

Does it matter if treatment doesn’t immediately make viral load undetectable?

The aim of HIV treatment is rapid and sustained suppression of viral load to below the limit of detection (between 50 to 20 copies/ml depending on the testing assay). Treatment guidelines suggest that viral load should reach this undetectable level six months after the initiation of treatment.

Does it matter if this target is not immediately achieved? An American study suggests that it does. People who had a viral load as low as 400 copies/ml six months after starting treatment had a greater risk of dying in the ten following years.

The researchers looked at data from approximately 8000 adults who started treatment between 1998 and 2014. Viral loads six months after starting treatment were examined.

The average ten-year mortality risk for people with a viral load below 20 copies/ml was 13%, similar to the 14% risk observed in individuals with a viral load between 20 and 400 copies/ml.

However the ten-year mortality risk was 20% for people with a viral load between 400 and 999 copies/ml, comparable to the 23% risk for people with a viral load of 1000 copies/ml or higher.

The researchers suggest that incomplete viral suppression six months after starting treatment may be a marker for several problems. Apart from lack of adherence to treatment or poor engagement with care, incomplete viral suppression might be a consequence of undetected drug resistance, or of drug-drug interactions that lead to low levels of antiretroviral drugs. Planning in advance to prevent these problems from undermining treatment, and prompt investigation of any problems, are likely to improve the chances of viral suppression, they say.

It’s important to note that this study dealt with not having an undetectable viral load six months after starting treatment. This is a different situation to achieving an undetectable viral load and then, months or years later, having small increases (‘blips’) in viral load. These do not predict treatment failure and are not problematic.

For more information, read 'Viral load' in NAM’s booklet ‘CD4, viral load & other tests’.

Western European countries close to 90-90-90 targets

Countries in Western Europe are well on their way to meeting the 90-90-90 targets set by the Joint United Nations Programme on HIV/AIDS (UNAIDS). The targets are for 90% of people living with HIV to be diagnosed, 90% of diagnosed people to be taking HIV treatment, and for 90% of people taking HIV treatment to have an undetectable viral load. It’s calculated that HIV will stop spreading and will be brought under control in countries which achieve these targets.

Researchers looked at data from 2013 in eleven countries: Austria, Belgium, Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden and the UK.

While only 78% of Greeks living with HIV were diagnosed, in all other countries the estimate was over 80%. In Denmark, Sweden and Italy, over 90% of people were diagnosed.

Of those diagnosed, the proportion taking HIV treatment was below 90% in only one country (76% in Spain). It was over 80% in all other countries, and was over 90% in Belgium, Austria, Denmark, France, the Netherlands and Sweden.

In all eleven countries, at least 80% of treated people had an undetectable viral load, with Denmark and Sweden achieving the 90% goal.

Estimates for the UK were 81% of people with HIV diagnosed, 82% of diagnosed people on treatment and 82% of treated people with an undetectable viral load.

The researchers say that the biggest challenge is the large numbers of people living with HIV in many countries who have never been diagnosed. Encouraging more people to test regularly is key to bringing other counties close to meeting these targets, they say.