HIV Weekly - 6th November 2013

Gay men and sexually transmitted infections

If you are sexually active there’s a chance that you could pick up a sexually transmitted infection (STI).

Good sexual health is important for everyone, but looking after your sexual health is particularly crucial for people with HIV. Having certain STIs can mean that you have an increased risk of passing HIV on to somebody else during unprotected anal, oral or vaginal sex. People with HIV are recommended to have regular sexual health check-ups as part of their routine HIV care.

In the last few years, particularly high rates of STIs have been reported in gay men in the UK and amongst migrant gay men in Europe.

Now a study looking at 40 large European cities has found that less than one third of men who have sex with men (MSM) had been screened for STIs in the last year.

In addition, most of the screening that was done involved blood tests only. While blood tests can diagnose some STIs (including syphilis), others (such as chlamydia and gonorrhoea) require a sample of urine or a swab from the penis as well as a swab from the rectum to be taken and tested, particularly if there are no noticeable symptoms. Less than half of all the STI screenings looked at in the study involved one of these other procedures, and only 18% of screenings involved a physical examination to look for anal or genital warts.

The types of screening offered varied significantly between cities, with men in Amsterdam, Birmingham, Dublin, London, Manchester and Stockholm more likely to be offered more than one sort of screening procedure.

In addition, one third of the study participants did not know whether they could get free or affordable sexual health screening where they lived. Men were particularly likely to report STI screening as being inaccessible in Brussels, Rome, Lisbon and many cities in eastern and central Europe and the Balkans. Over 90% of respondents in English cities said STI screening was freely available.

The researchers say that the findings of this study suggest that STIs are seriously under-diagnosed amongst MSM, and that countries that report high rates of STIs (such as the UK) may reflect more thorough screening services.

Another study has found that gay men are still at risk of infection with syphilis and urethral gonorrhoea even if they do not have anal sex.

STIs can be transmitted via a range of sexual activities. The researchers emphasised the importance of knowing that activities other than anal sex can still pose a risk for STI infection, and of regular testing for STIs in gay men.

Find out more about STIs and looking after your sexual health in our booklet HIV & sex.

The study of STI screening in Europe was conducted as part of the European Men Who Have Sex with Men Internet Survey (EMIS). This survey collected a wealth of data on the behaviour and HIV prevention needs of men who have sex with men living in Europe. See more aidsmap news reports on our EMIS features page.

HIV treatment – integrase inhibitors

New research has shown that the new antiretroviral drug dolutegravir is as effective, or more so, than other anti-HIV drugs prescribed for people starting treatment for the first time. Dolutegravir is from the newer integrase inhibitor class of drugs; it has already been approved in the US with the trade name Tivicay and is currently awaiting approval in Europe.

One study showed that the safety and effectiveness of dolutegravir therapy surpassed that of treatment based on ritonavir-boosted darunavir (Prezista). After just under a year, results were particularly good for people who had a high viral load before they started treatment.

A second study compared a combination including dolutegravir with one based on raltegravir (Isentress), the first approved integrase inhibitor. After almost two years, safety and effectiveness results were comparable between the two groups.

Dolutegravir’s manufacturer plans to produce a single-tablet regimen combining dolutegravir with abacavir and 3TC (the drugs contained in Kivexa). This would provide an alternative to the existing single-tablet regimens which all contain tenofovir and FTC (the drugs contained in Truvada), which could benefit people at risk of kidney or bone problems.

A further study concentrated on raltegravir (Isentress), the existing integrase inhibitor. While it is very effective and has fewer side-effects than many other antiretrovirals, its main disadvantage is that it has to be taken twice a day.

Now a French study has found that people whose viral load has already become undetectable on twice-daily raltegravir, or another treatment combination, can then safely swap to a once-daily dose of the drug.

Previous research showed that for people taking HIV treatment for the first time, the once-daily dose was not as effective in suppressing viral load as a twice-daily dose. This was particularly the case for people with high viral loads at the time they started treatment.

The new research was conducted with people who are already taking HIV treatment and have an undetectable viral load. It showed that people switching to once-daily raltegravir can maintain an undetectable viral load, as long as it is taken in combination with other drugs that are fully effective. This means that doctors prescribing a regimen including once-daily raltegravir need to look at the individual’s full treatment history and any resistance they may have to anti-HIV drugs.

These studies were presented at the 14th European AIDS Conference. See more news reports from this conference atwww.aidsmap.com/eacs2013.

HIV viral load

The aim of HIV treatment is an undetectable viral load. It’s not unusual for people whose viral load is undetectable to have the occasional ‘blip’ where their viral load goes up a little, temporarily, and then comes down again. But a larger increase in viral load, or one that continues to rise, can be a sign that treatment is no longer working effectively.

Now, an ongoing study in the UK has looked at whether there is a connection between baseline viral load (viral load levels at the time someone starts HIV treatment) and effectiveness of HIV treatment in the longer term.

Researchers found that people with higher baseline viral loads were more likely to experience viral load ‘rebound’ (two or more detectable viral load measures after being undetectable). The higher the baseline viral load, the more likely it was that a rebound would occur.

Ideally, viral load should become undetectable within six months of someone starting HIV treatment. Rebounds were also more likely in people who had taken longer to achieve an undetectable viral load, with people who had been on treatment for over a year before their viral load was undetectable at highest risk.

Results were similar whether people were taking drugs from the non-nucleoside reverse transcriptase inhibitor (NNRTI) class or the protease inhibitor class.

The researchers think that the study’s results suggest that clinicians should think carefully about which drugs people starting HIV treatment with a high viral load should take, and that they should monitor these patients closely, even after their viral load has become undetectable.

Another study has looked at viral rebound in people with low levels of HIV in the body. People can have an undetectable viral load according to the test most commonly used in clinics (which usually can’t measure levels under 50 copies/ml), but still have some HIV that can be detected by more sensitive tests. Italian researchers found that people with viral loads between 20 and 50 copies/ml were more likely to experience viral load rebound (about 16% of participants, compared to 8% of people without low-level viraemia).

You can find out more about viral load and viral load monitoring in NAM’s booklet, CD4, viral load & other tests.

These studies were presented at the 14th European AIDS Conference. See more news reports from this conference at www.aidsmap.com/eacs2013.

Treatment for hepatitis C

Many people living with HIV also have hepatitis C (often referred to as a co-infection). Liver disease caused by the hepatitis C virus (HCV) is an important cause of serious illness and death in people with this co-infection.

Hepatitis C can be treated and cured, but some types of hepatitis C are harder to treat, and cure rates can be lower in people who also have HIV. Current hepatitis C treatment can also have unpleasant side-effects. However, there are many new drugs and treatment strategies in development, which offer hope to people whose hepatitis has not yet been successfully treated.

A conference held in Washington this week heard about some of these new treatments.

A key aim is to develop a treatment for hepatitis C that does not include pegylated interferon, avoiding the drug’s side-effects and the need to take it by injection.

A major development in hepatitis C treatment has been the development of direct-acting antiviral drugs (DAAs, that is, drugs that attack the hepatitis C virus itself, unlike current standard treatment of interferon and ribavirin). These are effective as they can prevent the hepatitis C virus reproducing and quickly lead to it being eradicated from the blood and the liver.

Several new, interferon-free, combinations have been showing promising results:

• New drugs simeprevir and sofosbuvir may provide an all-oral HCV treatment that works for the harder-to-treat genotype 1 of HCV.
• A combination of three DAAs successfully cured 90% of people with genotype 1 HCV who had not been on treatment before.
• A two-drug combination of DAAs, with and without ribavirin, also showed good results in people with genotype 1.
• A two-drug combination of DAAs, without ribavirin, cured 95% of people with genotype 1 who had not been treated before and 90% who had previously tried treatment without success.
• A triple-drug regimen cured 100% of previously treated people with genotype 1 with serious liver damage (fibrosis or cirrhosis).

The DAA telaprevir (Incivek or Incivo) is already licensed for use in Europe. Another study found that adding telaprevir to the existing standard HCV treatment of interferon and ribavirin improved cure rates for HIV-positive men with hepatitis C, and reduced the length of time they needed to be on treatment.

You can read all the news from this conference on our Liver Meeting conference webpage.  

Interested in hepatitis and HIV? Visit our hepatitis C topics page for more resources, feature articles and news about hepatitis and HIV co-infection. We’re also working with ELPA, the European Liver Patients Association, on a hepatitis information website for patient advocates and professionals working in hepatitis in Europe – check it out at www.infohep.org

Treating HIV and TB at the same time

Worldwide, many people with HIV also have tuberculosis (TB), and it is a significant cause of illness and death. In the UK, it is one of the two most common AIDS-defining illnesses.

How and when each condition should be treated depends on the health of someone’s immune system. It is often recommended to delay HIV treatment until TB is under control. Some people start TB treatment first, and then start HIV treatment later. But if your CD4 cell count is low and you need to start HIV treatment soon, you may need to take treatment for both conditions at the same time.

Some treatment options for both TB and HIV include drugs that can affect the liver. But little was known about the effects on the liver of starting HIV and TB treatment together. A small study conducted in India has found that liver problems were rare in people on both types of treatment, if they had normal liver function to start with and weren’t also co-infected with a hepatitis virus.

Visit our Tuberculosis and HIV topics page for more resources and news about HIV and TB co-infection, treatment and care.