HIV update - 6th December 2017

Eight-week cure for acute hepatitis C

An eight-week course of sofosbuvir/ledipasvir (Harvoni) led to a sustained virological response in all people with HIV and acute (recently acquired) hepatitis C in a small study.

Researchers have recently been investigating how short hepatitis C treatment can be. Guidelines recommend a 12-week course of sofosbuvir/ledipasvir for people with chronic (long term) genotype 1 or 4 hepatitis C. Results for a six-week course were disappointing, but some easy-to-treat people do well within eight weeks. Could HIV-positive people who recently acquired hepatitis C (within six months of infection) be considered an easy-to-treat group? With modern drugs, having HIV and hepatitis C co-infection does not make hepatitis more difficult to treat. Also, recently acquired hepatitis C is easier to treat than long-term infection.

The study enrolled 26 people with genotype 1 and one person with genotype 4. Most were gay men. All were doing well on HIV treatment.

Participants took sofosbuvir/ledipasvir daily for eight weeks. Twelve weeks after completing treatment, all participants were undetectable for hepatitis C (SVR12). The treatment was generally safe and well tolerated.

The results suggest that an eight-week course is effective. But people with a high hepatitis C viral load before treatment did take longer to become undetectable, suggesting that for people with a very high viral load, a 12-week course might be more appropriate.

Some experts now believe that hepatitis C treatment should be started as soon as possible in acute infection, without waiting to see if the body clears the infection on its own (which happens in a fifth of cases). This is because treatments are now so safe and effective, with treatment able to lessen unpleasant symptoms, prevent liver damage and stop onward transmission of the virus.

For more information, read NAM’s factsheet ‘Hepatitis C and HIV’.

Yellow fever vaccination

Yellow fever is a viral infection, spread by mosquito bites, that people travelling to many African and South American countries need to get vaccinated against.

There is a risk of infection in many countries in central and west Africa, including Nigeria, Ivory Coast, Cameroon and the Democratic Republic of Congo, as well as Uganda and parts of Kenya. Brazil, Colombia and other South American countries are also affected. (See maps here.)

Yellow fever is prevented by a highly effective vaccine. However, it’s a live vaccine, which means that it should not be used by people living with HIV when they are unwell or have a CD4 count below 200. For HIV-positive people with stronger immune systems travelling to countries affected by yellow fever, vaccination is recommended.

Swiss clinicians have recently reported on their yellow fever vaccination programme. They assessed the proportion of people with HIV who had a protective immune response in the years following vaccination – this indicates that the vaccine could still protect them against yellow fever. Overall, this was the case for 95% of HIV-positive people one year after vaccination, 86% five years after vaccination and 75% ten years after vaccination.

Results were better for people with HIV who had an undetectable viral load at the time of vaccination. At each time point, 99% or more had a protective immune response.

The researchers recommend that people with HIV should be vaccinated against yellow fever when they have an undetectable viral load. If they remain on treatment, they can wait ten years before having a booster vaccination.

If people are vaccinated when their viral load is not undetectable, they should either have their immune response to the vaccine measured or get a booster vaccination straight away.

For more information, read the NHS’ information about yellow fever vaccination.

Cervical cancer

Untreated HIV raises the risk of cervical cancer, but taking HIV treatment reduces the risk. This has been shown by a review of 19 studies on the issue that included over 6000 women living with HIV.

Cervical cancer is linked to human papillomavirus (HPV), a very common viral infection. Taking HIV treatment strengthens the immune system’s ability to get rid of this infection and the review showed that women who were taking HIV treatment had a lower risk of having HPV in the cervix. Taking HIV treatment for a longer period of time further reduced the risk of having HPV.

Treatment also reduced rates of abnormal cell changes that are associated with a small risk of developing cervical cancer in the future. And women taking HIV treatment had less than half the rate of cervical cancer than HIV-positive women who weren’t taking treatment.

As well as taking HIV treatment, regular cervical screening (smear tests) are recommended for women with HIV. The test checks for abnormal cell changes so that you can receive prompt treatment to remove them. The British HIV Association (BHIVA) recommends that all women with HIV should have cervical screening soon after they are diagnosed with HIV, again after six months and then every year after that. This is more often than is recommended for women without HIV, who are offered this test every three years.

Your GP will need to know about your HIV status to ensure you are offered annual screening. You can talk to your HIV clinic staff if you would like them to arrange this with your GP. If you don’t have a GP, or haven’t disclosed your status to them, talk to staff at your HIV clinic about where to have regular cervical screening.

Drug resistance in Africa

While the number of people in higher-income countries who have resistance to anti-HIV drugs is falling, HIV drug resistance is increasing rapidly in southern and eastern Africa. Currently, around one in eight people starting HIV treatment in these regions already have resistance to at least one anti-HIV drug.

Often, this is because when they were first infected, they acquired HIV from someone who had had treatment problems and had drug-resistant virus. Resistance often develops when people stop taking their HIV treatment consistently and drop out of care.

Most often, people have resistance to efavirenz and other drugs of the same class (‘non-nukes’ or NNRTIs). This means that many countries need to change the drugs they usually offer for first-line treatment. A more modern drug, dolutegravir from the integrase inhibitor class, is now available at a low cost to low- and middle-income countries. It provides a good alternative, especially as very few people develop resistance to integrase inhibitors.

Health services in Africa also need to make it easier for people to attend regularly, so that fewer people drop out of care in the first place.

For more information, read ‘What is drug resistance?’ in NAM’s booklet ‘Taking your HIV treatment’.