HIV treatment continues to get better

The efficacy of first-line HIV treatment continues to improve, according to an analysis of outcomes in 78,000 people in 181 separate studies. Outcomes in people starting treatment in recent years are better than those in people who started treatment in the 1990s or 2000s.

The researchers wanted to find out how many people were still on the same drug combination and with an undetectable viral load, two years after starting their treatment.

In people starting treatment between 1994 and 2000, it was 52%. Between 2001 and 2005, it was 61%. In 2006 to 2010, the figure rose to 65%. And in the most recent period included, 2011 to 2015, 80% still had an undetectable viral load after two years on the same treatment.

Almost everyone who did not do well on their first treatment switched to an alternative drug combination which suited them better.

The study contained some pointers to which drug combinations are likely to have the greatest success. People starting treatment with integrase inhibitors (such as dolutegravir or raltegravir) were more likely to still be on their first-line treatment three years later. People using a nucleoside backbone of tenofovir and emtricitabine also did well.

Once a day dosing (rather than twice a day) had a greater impact on effectiveness than the number of pills taken.

But good as these results are, the researchers believe that it’s still possible to do better. They note that even with the most modern treatment regimens, a fifth of people stop or change their treatment regimen within two years of starting.

Drug-drug interactions

The more medication you take, the greater the risk of experiencing drug interactions and side-effects. A drug interaction is when one medication adversely affects how another medication works, by decreasing its effectiveness or increasing the risk of side-effects.

The importance of keeping an eye on drug interactions is shown by an analysis of over 185,000 Americans who took HIV treatment over the past decade. One quarter were taking statins, which lower cholesterol and help prevent heart disease. Some statins have the potential to interact with certain antiretrovirals and other medications taken by people with HIV, causing statin-related side-effects such as muscle pains and kidney damage.

Amongst people taking statins, around 10% were taking them together with another medication with the potential for a drug-drug interaction. In many cases, the anti-HIV drugs which could interact with a statin were cobicistat (Tybost) and ritonavir (Norvir).

Both of these are boosting agents, taken to boost levels of other antiretrovirals. The boosting mechanism can also raise or alter levels of other medications, including statins.

• If your HIV treatment includes a protease inhibitor, you are probably taking a booster. Protease inhibitors include darunavir (Prezista), atazanavir (Reyataz) and lopinavir (Kaletra).

• Cobicistat is also taken with the integrase inhibitor elvitegravir (Vitekta). Cobicistat is included in the combination pills Stribild, Genvoya, Symtuza, Rezolsta and Evotaz. Ritonavir is also in a combination pill used to treat hepatitis C called Viekirax.

• The two statins that should never be taken with boosters are lovastatin and simvastatin, but all have some interaction with boosters.

The researchers say that potential drug-drug interactions need to be considered when people with HIV are prescribed statins.

When you are prescribed a new medication, it’s important to tell the doctor or pharmacist about all the other medications that you take. You should ask whether the new medication could interact with them and if so, what side-effects to watch for.

For more information, read NAM's factsheet 'Multiple medications and drug interactions'.

Visit the University of Liverpool's HIV Drug Interactions website to check possible drug interactions.

Missed menstrual periods

Women living with HIV may have a higher risk of the menstrual disorder amenorrhea (missing three of more consecutive periods), but the research evidence on this is limited, researchers have found. They reviewed the medical literature for all studies comparing missed periods in women living with HIV and in women without HIV. They excluded studies of women who were going through or had gone through the menopause.

They were only able to find six relevant studies and most of the data were collected in the 1990s. Five studies came from the United States and one from Nigeria.

Weakened immune systems and low body weight could contribute to menstrual problems. These issues could both have been more common in the 1990s than they are now, as effective HIV treatment is now available.

Overall, the researchers found that 5% of women with HIV had missed periods. This rate was higher than in women who didn’t have HIV. Women with HIV and a low body weight were especially likely to miss periods.

The complications of this menstrual disorder can include infertility, bone problems, heart disease, depression, anxiety and sexual dissatisfaction. The researchers say that doctors should regularly ask women living with HIV about when they last had a period, to identify problems early.

For more information, read 'HIV and your body' in NAM's booklet 'HIV & women'.

Progress towards an HIV vaccine

In a step forward in the search for an HIV vaccine, scientists in California have manufactured an HIV vaccine that caused monkeys to produce broadly neutralising antibodies (bNAbs).

These complex molecules, which naturally develop in some people with HIV after years of infection, stop the virus from infecting cells. If a vaccine could make people produce their own bNAbs, their immune system would have a stronger and more complete response to HIV. This might prevent HIV infection altogether.

Professor Denis Burton of the Scripps Institute aimed to show that a single shot of a vaccine could achieve protective levels of bNAbs. This happened in six of the 12 monkeys that the experiment was done on.

He also wanted to find out whether these antibody responses would protect the animals against infection with a monkey-adapted form of HIV (simian HIV). Infection was delayed in all monkeys and in two of them, it was completely prevented.

This is the first time that effective broadly neutralising antibodies (bNAbs) to any infection have been generated in any mammals other than cows by vaccinating them.