Are condoms needed when viral load is undetectable?

At a recent medical conference, doctors debated whether men living with HIV who have an undetectable viral load should be advised to wear condoms.

Dr Lisa Winston argued that condoms were still needed for three main reasons:

• Condoms prevent transmission of other sexually transmitted infections (as well as HIV). These infections are not always easy to treat (e.g. drug-resistant gonorrhoea) or without serious consequences (e.g. hepatitis C).
• HIV that is undetectable can become detectable, for a variety of reasons including missing doses of antiretrovirals and concurrent illnesses. 
• HIV transmission is theoretically possible when viral load is undetectable in plasma or semen. "If you observe enough people for a long enough period of time, you probably will see occasional transmissions – they will be rare, but they are likely to occur," Dr Winston said. "What is your appetite for risk when advising patients?"

Countering these arguments, Dr Roy Gulick reminded the audience of the many studies of HIV transmission within serodiscordant couples which have not identified any linked infections when the HIV-positive partner was on treatment with an undetectable vial load. These include the key randomised study known as HPTN 052, the PARTNER study which has data on 58,000 sex acts and a meta-analysis of six studies with a total of 7000 couples.

"Lisa tried to scare us, as people have been doing for many years," Dr Gulick said. "We should not spend time worrying about things that don't happen very often at all. I've presented data on more than 15,000 serodiscordant couples, all suppressed on antiretroviral therapy. How many transmitted HIV to their seronegative partner? Zero."

Nonetheless, two-thirds of the audience of clinicians voted to recommend that HIV-positive men with undetectable viral load should always wear a condom. It’s possible that healthcare providers may be more risk-averse about health-related behaviour than the population at large – especially when it comes to sex, and even more so gay sex.

For more information, see NAM’s factsheets ‘Viral load and transmission – a factsheet for people with HIV’ and ‘Unprotected sex’.

More side-effects with dolutegravir than expected

Insomnia, dizziness, headache and other central nervous system side-effects are occurring more frequently with everyday use of dolutegravir than clinical trials had suggested, two new studies show.

Dolutegravir (Tivicay, also combined with abacavir and lamivudine in Triumeq) is an integrase inhibitor that is recommended as one of the preferred options for first-line treatment in treatment guidelines. Experimental treatment simplification strategies, with fewer drugs being taken, often include dolutegravir because it is such a potent drug.

Moreover, dolutegravir has been thought to cause relatively few side-effects, especially in comparison with efavirenz and some other antiretroviral drugs.

However, German doctors have found that around one in twenty people starting treatment with dolutegravir switched drugs within the first year, because of side-effects. Dutch doctors found that one in seven switched drugs. The most common problem was disturbed sleep, with dizziness, headache, pins and needles, gastrointestinal complaints, problems concentrating or thinking, and depression also reported by several people.

In both studies, people taking dolutegravir together with abacavir (for example, by taking the Triumeq tablet) were more likely to have problems. This might be due to an interaction between the two drugs.

In the German study, women and people over the age of 60 were also more likely to need to switch drugs.

For more information on dealing with side-effects, read NAM’s booklet ‘Side-effects’.

Smoking causes more harm than HIV

Smoking has the potential to shorten the life of a person taking HIV treatment by an average of six years, and is far more harmful to the life expectancy of people living with HIV than well-managed HIV infection itself, an American modelling study suggests.

Smoking reduces life expectancy through heart attacks, strokes, cancers and chronic obstructive pulmonary disease (emphysema). Many studies have found that rates of smoking are higher in people living with HIV than in the wider population.

The new study is based on American people living with HIV who are diagnosed and start HIV treatment at the age of 40. It found that:

• Men who continued to smoke had an estimated life expectancy of 65 years.
• Men who quit smoking at the age of 40 would live to the age of 71 years.
• Men who had never smoked had a life expectancy of 72 years.

Women are expected to live for longer:

• Women who continued to smoke would live to 70 years.
• Women who quit smoking at 40 had an estimated life expectancy of 73 years.
• Women who had never smoked would live to the age of 74 years.

The researchers found that stopping smoking at the age of 40 was associated with greater gains in life expectancy for both men and women than starting HIV treatment with a CD4 count above 500, compared to starting late.

"It is time to recognise that smoking is now the primary killer of people with HIV who are receiving treatment," commented the researchers. They say that HIV services need to integrate smoking cessation into their programmes.

There’s more information in NAM’s factsheet ‘Smoking’.

News from HIV Glasgow 2016

This recent conference included several interesting studies which are relevant to people living with HIV in the UK. As a subscriber to HIV update, you should have received an email conference bulletin last week.

You can also read the bulletin online here. It includes news on new treatment strategies, the long-term health consequences of lipodystrophy, the safety of purchasing hepatitis C and pre-exposure prophylaxis (PrEP) drugs online, and the complexity of the medical needs of older people living with HIV.