When to start HIV treatment
There’s always been a lot of debate about the best time to start HIV treatment. Guidelines in the US recommend treatment for everyone diagnosed with HIV.
However, UK, European and World Health Organization guidelines take a more cautious approach. For most people diagnosed with HIV, treatment is recommended when their CD4 cell count falls to 350.
Some doctors think this is too late. There is some evidence that treatment at higher CD4 cell counts reduces the risk of serious illness and death. Moreover, the current threshold for starting treatment may be too low for the full potential of HIV treatment as prevention to be realised.
In the latest research, investigators compared mortality rates between people with HIV and their HIV-negative partners, enrolled in the Partners in Prevention study.
As expected, rates were higher among those with HIV: 74 HIV-positive people died during the study period compared to 25 HIV-negative partners.
The researchers looked in more detail at the CD4 cell counts of the people with HIV who died. Compared to people with a CD4 cell count above 500, those with a CD4 cell count between 350 and 499 were almost twice as likely to die. The risk of death was even higher for people with lower CD4 cell counts.
The main implications of this study are for low- and middle- income countries, where many people living with HIV don’t start treatment until their CD4 cell count is below 200 or even lower.
However, it’s also likely to be of interest to people in other settings, where there is a lot of discussion about the pros and cons of treatment at higher CD4 cell counts. A very large randomised trial is currently underway to see if early treatment does have any benefits. Its results are eagerly awaited.
For more information on HIV treatment, you may find our Anti-HIV drugs booklet useful. Along with the other booklets in the series, it is available at www.aidsmap.com/booklets.
HIV and cognitive impairment
Cognitive impairment involves problems with memory and concentration, as well as a general decline in mental ability. It can be a natural consequence of growing older and is often so mild that it doesn’t really have any impact on day-to-day life.
However, it’s also been linked to a number of long-term health issues, including HIV.
Some research has shown that people with HIV have an increased risk of cognitive impairment, even when they’re doing well on HIV treatment. There has been concern that HIV may be the main cause of these problems.
But the results of the latest research suggest that traditional risk factors are the most important cause.
French researchers found that 59% of people receiving routine HIV care had some form of impairment. The average age of study participants was 47 and 85% were taking HIV treatment. In 20%, the impairment was so mild that it didn’t have any symptoms.
No HIV-related factor was associated with an increased risk of impairment.
Instead, the most important risks were those seen in the general population, for example cardiovascular disease and mental health problems such as anxiety and depression.
When the researchers restricted their analysis to people without cardiovascular risk factors they found that the proportion with impairment fell to 10%.
The researchers recommend that screening for neurocognitive impairment should be especially targeted at people with traditional risk factors.
You can find out more about previous research on this subject in the news section of aidsmap.com.
HIV risk behaviour
It’s now widely accepted that infectiousness is reduced when viral load is kept under control by antiretroviral therapy.
However, there are some concerns that being aware of this could mean that people taking treatment are more likely to have unprotected sex or engage in other HIV risk behaviours.
Researchers in the US city of Baltimore wanted to see if this was the case.
Their research involved 362 people living with HIV with a history of injecting drug use. Rates of unprotected sex and unsafe injecting practices were monitored for a year before the study participants started HIV treatment and for up to five years afterwards.
Starting HIV treatment was accompanied by a 75% reduction in the proportion of people reporting unprotected sex.
There was also a 38% fall in the proportion reporting injecting drug use.
But a small proportion of people who were actively injecting before they started treatment were even more likely to report unsafe injecting practices after initiating therapy.
Overall, the researchers were encouraged by their findings. They recommend that HIV prevention efforts should be especially targeted at people who report risky behaviour in the period before they start treatment.
Take a look at our Transmission and viral load resource, designed to support conversations around sexual transmission and HIV treatment. For more detailed information, visit our HIV treatment and sexual transmission factsheet or our online Preventing HIV resource.
Editors' picks from other sources
Brief treatment interruptions for cure studies are safe, well-tolerated
from AIDSMeds
Short treatment interruptions of HIV antiretroviral regimens are both safe and well-tolerated among people with HIV. The average study participant took two weeks to reach a detectable viral load and another two weeks, after restarting antiretroviral therapy, to reach full viral suppression once again.
South Africa: Easy patents cost patients
from IRIN Plus News
South Africa grants almost every patent application it receives, making its patent regime one of the world's most lenient. While pharmaceutical companies cash in, patients face staggering healthcare costs, and medicines like cancer treatments, third-line antiretrovirals and treatments for drug-resistant tuberculosis are often priced out of reach.
Is protease inhibitor monotherapy sufficient to keep HIV under control in the brain?
from CATIE
Researchers have been conducting clinical trials of simplified therapy – particularly based on a protease inhibitor boosted with a small dose of ritonavir (Norvir). This is generally called protease inhibitor monotherapy (PI monotherapy). But recently, two teams have separately reported that their data strongly suggest that injury to cells within the brain has occurred in some participants when exposed to PI monotherapy.
Australia: New HIV campaign weighs up risk reduction
from ACON press release
A new HIV prevention campaign is aiming to increase gay men's knowledge about the degrees of risk involved in not using condoms when they're having sex. The campaign gives frank, factual information about 'strategic positioning', serosorting and undetectable viral load.