The benefits of prompt HIV treatment

Further findings from START, a major study which aimed to identify the benefits and harms of beginning HIV treatment at a high CD4 cell count, have recently been released. These findings concern cancer, heart disease and quality of life.

This study enrolled 4685 men and women with HIV who had never taken HIV treatment, were in generally good health and had a CD4 cell count over 500 cells/mm³. Based on random allocation, half the participants started HIV treatment immediately, while the other half deferred treatment until their CD4 cell count declined to 350 cells/mm³. As has already been reported, people who began HIV treatment immediately had a 57% reduction in serious illnesses and death.

Many of the serious illnesses that are prevented by prompt HIV treatment are cancers. A new analysis showed that HIV treatment has a particular impact on cancers which are linked to viruses and other infections, reducing them by 74%. Examples of these cancers are Kaposi’s sarcoma (linked to human herpes virus 8), Non-Hodgkin’s lymphoma (linked to Epstein-Barr virus), cervical cancer (human papillomavirus) and anal cancer (also human papillomavirus). HIV treatment also reduced the rate of cancers without infectious causes – such as prostate or lung cancer – by 51%.

However prompt HIV treatment did not make any difference to rates of heart attack and stroke, or an important early warning sign of heart disease (the elasticity of major arteries). When the START study was planned, many experts believed it would show the benefits of prompt HIV treatment in preventing heart disease, but in fact HIV treatment’s benefits have turned out to be different.

The question that still puzzles researchers is whether HIV-associated heart disease is primarily driven by the immune system being weakened (in which case, earlier HIV treatment should prevent heart problems) or by the immune system’s ongoing inflammation and activation as it attempts to deal with the infection (in which case, rates of heart disease may remain high in people living with HIV).

The study also found that rather than treatment side-effects having a negative impact on people’s quality of life when they start HIV treatment, quality of life actually improved. Study participants rated their own health-related quality of life on a regular basis with a range of questions, giving them the opportunity to note the impact of any drug side-effects, symptoms, pain or mood changes on their day to day life.

People who began HIV treatment said they had a better quality of life than those who were were not taking it. The difference was not large but it was statistically significant. The findings should provide reassurance to people who worry about HIV medications being ‘strong’, ‘toxic’ or causing more harm than good.

Overestimating the risk of HIV infection

Many Americans living with HIV considerably overestimate their risk of passing HIV on, according to a study. Between 2011 and 2014, people taking HIV treatment as part of a clinical trial were asked: “How likely would you be to give someone HIV if you had unprotected sex with them today?”

After two years of HIV treatment – when 90% of trial participants in fact had an undetectable viral load and so were highly unlikely to pass HIV on – 36% thought they were highly infectious, 19% rated the risk as ‘medium’, 33% as ‘low’ and 12% thought they were not infectious. People’s beliefs about their infectiousness bore little relationship to their actual risk.

People may have been receiving over-cautious messages from healthcare staff and HIV stigma may have influenced people to express negative beliefs about themselves. When Dr Raphael Landovitz of the University of California, who conducted the study, was asked what message patients should be given about viral load and infectiousness, he said: “Don’t give them a dumbed-down message and talk in absolutes. In my experience, people want nuanced information about their risk of infecting others and want to be able to make up their own minds.”

Life expectancy gap

A study comparing HIV-positive and HIV-negative people in California has found that although life expectancy in people with HIV has improved, life expectancy at age 20 remains 13 years behind that of matched HIV-negative people.

Data came from around 25,000 HIV-positive clients of Kaiser Permanente (a health insurance and health care provider) and from ten times that number of HIV-negative clients.

In 1996, a 20-year-old person with HIV could only expect to live to the age of 39, but by 2011 a person with HIV of that age could expect to live to 73. Despite the improvement, life expectancy did not reach that of HIV-negative people – they could expect to live to their mid-eighties.

The researchers also looked at the life expectancy of people with HIV when risk factors for poor health were absent. Starting antiretroviral therapy with a CD4 cell count over 500 cells/mm³ added five years to life expectancy, not having hepatitis B or C added six years, and not having a history of drug and alcohol problems added six years.

The biggest difference was due to smoking – having never smoked raised life expectancy by almost eight years, but still left a gap of five years in comparison with HIV-negative people.

Six-week treatment for acute hepatitis C in people with HIV

Treatment with sofosbuvir/ledipasvir (Harvoni) for six weeks is enough to cure acute hepatitis C in people with HIV who have a low hepatitis C viral load.

The study involved 26 HIV-positive people with recent hepatitis infection (within the past six months) in Germany and the UK. All had genotype 1 or 4 infection. They only received treatment for six weeks, rather than 12 or 24 weeks.

Twelve weeks after the completion of treatment, 77% of participants had a sustained virological response (considered a cure for hepatitis C). There were no serious adverse events and the most common side-effects were tiredness and headache.

Treatment was especially efficacious in people with lower hepatitis C viral loads – the researchers recommend longer courses of therapy for people with higher viral loads.