HIV update - 12th December 2018

Good news about the state of the HIV epidemic

Public Health England’s annual report shows that there has recently been great progress towards ending the HIV epidemic in the United Kingdom.

During 2017, new diagnoses fell by 17% on the previous year. The report describes an epidemic in which new diagnoses fell in gay men, heterosexuals and all other groups; in people born in the UK and immigrants; in people of all ethnicities and age groups; and in virtually all regions of the UK.

For the first time, diagnoses are falling among white heterosexuals as well as among black and Asian gay men. While 42 children born with HIV were diagnosed in the UK last year, all the transmissions occurred overseas and the UK has seen no cases of in-country mother-to-child transmission for two years.

Of all people with HIV, it is now estimated that 92% have been diagnosed. Of those diagnosed, 98% are taking treatment. Of those taking treatment, 97% have an undetectable viral load. The UK is surpassing the United Nations’ 90-90-90 targets, which say that each of these figures should be above 90%. As a result, an estimated 87% of people with HIV in the country have an undetectable viral load.

It’s a similar picture in a few other countries in western Europe, such as Portugal, Spain, Switzerland and the Netherlands. In these countries, the annual number of new diagnoses has almost halved since 2008.

But the picture is much more depressing further east. Two-thirds of all new HIV diagnoses in the European region now occur in the single country of Russia (16% of the European population but 65.5% of the HIV diagnoses). Access to treatment remains the biggest single reason for the ongoing epidemic in eastern Europe. Countries like Russia have high rates of HIV testing but only 36% of people diagnosed are able to get treatment.

Guidelines on HIV treatment in pregnancy

The British HIV Association (BHIVA) is the professional association of HIV clinicians in the UK. They have recently updated their guidelines for HIV treatment in pregnancy and after birth. Among the highlights:

• All women living with HIV not already taking HIV treatment should begin it during pregnancy. The preferred regimens are based on efavirenz or atazanavir/ritonavir, due to there being more data on the safety of these drugs.
• Women who are already taking HIV treatment when they become pregnant will usually be able to continue with the same medications, although there are a few exceptions. For example, there are some concerns about using dolutegravir in the first eight weeks of pregnancy.
• The advice on infant feeding has been updated. Bottle feeding with formula milk is the safest way for a mother with HIV to feed her baby as this eliminates any risk of passing HIV on. However, the guidelines recognise that some women will choose to breastfeed and make recommendations for how clinicians can advise and support women who do so.
• After birth, babies usually take an HIV medication for a few weeks (known as infant prophylaxis). The guidelines say that for infants at very low risk of HIV transmission (whose mothers have very well controlled HIV), this should last for two weeks, instead of the usual four weeks.
• Healthcare staff should assess women for depression during pregnancy and in the months after giving birth. Pregnant women living with HIV should be offered peer support.

For more information, read NAM's leaflet 'Having a baby'.

CD4 recovery

Most people who start to take HIV treatment and achieve an undetectable viral load also see their CD4 cell count (an indication of the strength of the immune system) rise, above the threshold of 500 cells. But this doesn’t happen for everyone, a new study shows.

French researchers tracked over 6000 people who started treatment with a CD4 below 500 between 2006 and 2014 and subsequently had an undetectable viral load. Data was collected for up to six years for each person – longer than many studies, but perhaps not long enough as some people’s CD4 count can take more than a decade to recover.

Overall, 70% of people had ‘CD4 recovery’ (at least two CD4 counts over 500). However, 12% continued to take their treatment but did not have a CD4 recovery. The remaining people did not have complete medical records, had dropped out of care, or had died.

People who started treatment with a relatively high CD4 count were most likely to have a CD4 recovery. This shows why it is important to test and treat HIV as early as possible.

• Starting treatment with a CD4 count below 100 – 20% had CD4 recovery.
• Starting treatment with a CD4 count between 100 and 200 – 38% had CD4 recovery.
• Starting treatment with a CD4 count between 200 and 350 – 68% had CD4 recovery.
• Starting treatment with a CD4 count between 350 and 500 – 87% had CD4 recovery.

The researchers also found that people who had a higher CD4/CD8 ratio (another marker of the immune system) at the time of starting treatment were more likely to have a good recovery. Older people and individuals who had illnesses had poorer chances.

For more information, read NAM's factsheet 'CD4 cell counts'.

Bone fractures and HIV medications

A new French study has found no links between any anti-HIV medications and bone fractures. People living with HIV who had broken a bone after a fall or similar accident were compared with other people who had not broken a bone.

In particular, people taking tenofovir disoproxil fumarate (TDF) were not at increased risk of a fracture, although this medication has a reputation for causing bone problems. TDF is a component of Truvada and Atripla and their generic equivalents, as well as Eviplera and Stribild. 

A newer, more expensive version of the drug is called tenofovir alafenamide (TAF). It is thought to be safer for both the bones and the kidneys. TAF is a component of Odefsey, Genvoya, Symtuza, Descovy and Biktarvy.

But the French study calls into question the potential safety benefits of the new form of tenofovir (TAF) over the much cheaper, older version (TDF), in relation to fractures specifically. In the study, there were no statistical associations between fractures and specific anti-HIV medications.

For more information, read NAM's factsheet 'Bone problems and HIV'.