News in brief

Treatment breaks permanently harm immune recovery

Patients who took breaks from treatment (‘drug holidays’) had substantially poorer CD4 count increases and substantially higher rates of death and AIDS, a study of 2700 patients from the Swiss HIV Cohort shows.¹

The poorer outcomes persisted over a seven-year period, even though the average cumulative time off HIV treatment was only nine months.

Patients started combination therapy between January 1996 and July 2008. They fell into three groups. Just over half of all patients had treatment interruptions (‘interruptors’); 20% stayed on medication but had at least one viral load over 1000 copies/ml (‘non-suppressors’); and 30% maintained a viral load under 1000 copies/ml (‘suppressors’).

Death rates differed dramatically. The annual death rate in interruptors was one death in every 51 patients, over five times higher than the annual rate in suppressors (one death in every 270 patients) and twice as high as non-suppressors (one death per 103 patients).

Over twice as many interruptors developed an AIDS-defining illness after starting treatment (10.5%) than suppressors (4.5%), and 75% more than non-suppressors (6%).

The longer the treatment break, the poorer the response: CD4 counts in people who had had cumulative time off therapy of more than 2.5 years actually declined over the seven-year period.

Increase in strokes in US HIV patients

A study from the US has found a 43% increase in the annual incidence of hospital admissions due to strokes in people with HIV between 1997 and 2006, compared to a 7% decline in the general population during that period. Hospital admissions for stroke rose from one in every 1250 HIV-positive patients per year to one in 555.² The study found that the absolute number of strokes in people with HIV went up 60% and the proportion of stroke patients who were HIV-positive went up 67%.

The likelihood of suffering a stroke, severity, and the mortality rate have been declining since the 1950s; in contrast, these data do not suggest that strokes are declining in people with HIV. This may be due to risk factors being more common, such as high blood pressure, diabetes, chronic lung and kidney disease, and a more than sixfold higher risk in people with ‘mild’ liver disease.

US treatment guidelines change

The latest US HIV treatment guidelines were published on 10 January.³ These contain fewer and less contentious changes than the last set, which had a lack of consensus on whether to start treatment at CD4 counts over 500.

The updated guidelines extend treatment regardless of CD4 count to patients with tuberculosis, recommending that HIV treatment should be started within four to eight weeks of starting TB treatment, depending on CD4 count. The most radical change is a redefinition of ‘virological failure’ to mean a viral load of over 200 copies/ml. This is to rule out viral load ‘blips’ or variations in assays.

The only licensed antiretroviral drug in the CCR5 inhibitor class, maraviroc (Selzentry in the US, Celsentri in Europe), is added to the list of drugs recommended for first-line use, though enough data on potential combinations only exist on use with Combivir (AZT/3TC) so far.

A resistance test for integrase inhibitors is recommended when failure of a regimen containing these drugs occurs. Finally the protease inhibitor saquinavir (Invirase) is downgraded to ‘use with caution’ after reports of heart irregularities in HIV-negative people.

HIV services to be commissioned nationally

It was announced on 21^st December that the UK government proposed to commission HIV services nationally, instead of devolving commissioning to GPs, as is the case for most other conditions. A rearguard action by HIV organisations appears to have ensured that HIV remains a specialist area, allowing efficiencies to be made in the procurement of drugs and services.

It also proposes that genitourinary medicine (GUM) services are taken out of NHS management and commissioned by local authorities as part of their public health remit.

These proposals are out for consultation until 31^st March.⁴

Local authorities are likely to be legally required to provide open-access sexual health services, but with some flexibility about how they do so.

Lisa Power, head of policy at the Terrence Higgins Trust, said it was estimated open-access sexual health services would swallow around 20% of the whole public health budget.

There are concerns that no money will be left for HIV and STI prevention and information activities, especially in competition with other public health priorities. Some national campaigns may be commissioned, but there is no specific mention of the national HIV-prevention programmes CHAPS and NAHIP.

New 'non-suppressive' drug: first results

Seattle-based company Koronis has announced first human trial results for a drug, KP1461, that has, for HIV therapy, a radically different mode of action.⁵ It does not stop HIV from replicating, but accelerates the rate at which HIV mutates. The idea is that runaway mutations will so degrade HIV’s reproductive fitness that viral load will eventually start to fall anyway.

Tests on 80 volunteers have so far shown that KP1461 appears safe and produces the expected mutation rate. The next trials will focus on whether this produces an eventual decrease in viral load, and to see how this drug could be combined with conventional suppressive approaches.

Gay men’s HIV risk remains high, but testing rates increase

The most recent UK Gay Men’s Sex Survey (GMSS) report⁶ reveals that over half of respondents had unprotected anal sex at least once in the previous year. It also finds a continued increase in the proportion of gay men who have tested for HIV.

Of 7461 men answering the 2008 GMSS, 54% had had unprotected anal sex at least once during the previous year. This is nothing new: over 50% of respondents who have anal sex have reported unprotected sex in every GMSS since 2000, from a low of 32% in 1994⁷ and a study from Amsterdam has reported almost exactly the same changes over time in unprotected anal sex in gay men.⁸

One in five HIV-negative men reported the riskiest sex for HIV acquisition (unprotected receptive anal sex with a partner of positive or unknown status). This was most common in men under 20. Over a quarter of HIV-positive men reported the riskiest sex for HIV transmission (taking the insertive role in unprotected anal sex with someone of negative or unknown status). Men in their 30s were most likely to take this risk.

HIV testing rates continue to rise, with 72% reporting having taken an HIV test at least once. However, only 46% of non-HIV-positive men reported having taken a test in the past year.

HIV prevalence varied significantly round the country, with 15% of men in London and north-west England reporting having HIV, but only 3.5% in the East Midlands and 1% in Northern Ireland.