Starting HIV treatment
There’s currently renewed debate about the best time to start HIV treatment.
Treatment guidelines in the UK take a cautious approach recommending that most people living with HIV should start taking anti-HIV drugs when they have a CD4 cell count of around 350. However, much earlier treatment is recommended in US guidelines and some doctors believe that HIV treatment would be beneficial for all patients, regardless of their CD4 cell count.
The authors included senior HIV doctors and researchers as well as a community representative.
They looked at several sets of HIV treatment guidelines. The recommendations in these guidelines about the best time to start therapy varied considerably. The authors also found that the way in which the guidelines evaluated the strength of evidence from clinical trials and other studies was very inconsistent. This is why the various guidelines make different recommendations about when to start treatment.
We are still awaiting the results of a large clinical trial (called ‘START’) to see if starting HIV treatment with a CD4 cell count above 350 has extra benefits. At the moment, recommendations in the US and some other guidelines about the use of treatment at higher CD4 cell counts are based on data from studies that have monitored groups of patients over a number of years. The authors point out that not all the data from these studies show that starting HIV treatment with a higher CD4 cell count has extra benefits.
We recently worked with BHIVA to produce summaries of the most recent BHIVA guidelines for HIV treatment and care: www.aidsmap.com/uk-treatment-guidelines
HIV and pregnancy: vaginal delivery
Opportunities are being missed for pregnant women living with HIV – if they have a low viral load – to have a vaginal delivery, European research shows. Up to a third of women who were candidates for a vaginal delivery were nevertheless having an elective caesarean section.
An elective caesarean section – a caesarean before the onset of labour or the rupture of membranes – was recommended for women living with HIV in 1999 when it was shown to reduce the risk of vertical (mother-to-child) transmission of HIV, compared to vaginal delivery.
Use of HIV treatment during pregnancy and delivery can reduce the risk of mother-to-child HIV transmission to 0.1%. The additional benefits of an elective caesarean section are therefore open to question, especially as the procedure can involve risks.
Over the past decade, guidelines across Europe for the management of HIV and pregnancy have changed and now allow or recommend a vaginal delivery if a woman is taking HIV treatment and has a low viral load.
Researchers wanted to see if these guidelines were being applied.
They examined information on over 3000 deliveries between 2000 and 2010.
The proportion of women giving birth vaginally increased from 17 to 52% after the introduction of the new guidelines.
The researchers focused on the 611 deliveries where the mother was a candidate for a vaginal delivery.
They found that 45% of women with an undetectable viral load and 57% of those with a viral load between 50 and 399 copies/ml had a vaginal delivery. Approximately a fifth of deliveries were by emergency caesarean section.
However, 35% of women with an undetectable viral load who could have attempted a vaginal delivery nevertheless had an elective caesarean section.
The researchers believe there are “missed opportunities” for vaginal deliveries in women with a suppressed viral load.
Cannabis and liver disease in people with HIV and HCV co-infection
Smoking cannabis doesn’t worsen liver damage associated with hepatitis C virus (HCV) in people with HIV co-infection, according to new research.
Large numbers of people with HIV have HCV co-infection. Liver disease caused by HCV is an important cause of serious illness and death in this group.
The results of research examining the impact of smoking cannabis on the progression of liver disease in people with HCV or HIV is contradictory and inconclusive.
Therefore researchers in Canada monitored the progression of liver disease in 690 people with co-infection according to their use of cannabis.
The participants were monitored for approximately two and a half years and over half reported using cannabis, with up to 50% of these participants saying they used the drug to relieve symptoms.
There was no difference in the rate of progression to serious liver disease between users and non-users of cannabis.
“We could not demonstrate any important effect of marijuana on liver disease outcomes,” conclude the authors.
Editors' picks from other sources
How to whitewash a plague
from New York Times
A review of the New York Historical Society’s current exhibition “AIDS in New York: The First Five Years” suggests that someone without prior knowledge of the epidemic could easily leave without understanding the bitter, hard-fought battles that activists waged to gain treatment.
These renderings of HIV show that a deadly virus can be beautiful
from Gizmodo
For those of us who are normal, non-scientist people, an image of a virus doesn't necessarily hold any meaning. However, artists were recently invited to create renderings of HIV, and the winning images are as educational as they are beautiful.