Guidelines recommend treatment for all

New treatment guidelines have been published by both the British HIV Association (BHIVA) and the World Health Organization (WHO). Both clearly recommend that all people living with HIV should take HIV treatment.

This is not a surprise – key points from the two guidelines were made public earlier in the summer.

But it is now confirmed that in the UK, anyone living with HIV who understands the commitment of treatment and is ready to start should receive treatment, regardless of CD4 cell count.

Doctors should talk to their patients about the evidence showing that people who begin HIV treatment earlier have better long-term health outcomes than people who delay treatment. They should also discuss the evidence showing that treatment also substantially reduces the risk of passing HIV on to other people. The decision to start treatment rests with the person living with HIV.

The same recommendation is made by the World Health Organization.

Cancer risks

A large and well-conducted study on the risk of developing cancer has just been published. In recent years, cancer has become more common among people living with HIV – partly because people with HIV are living longer. HIV’s impact on the immune system also contributes to high cancer rates.

The researchers looked at data on 86,620 people living with HIV in the US and Canada, comparing them with almost 200,000 people who don’t have HIV. The data come from 1996 to 2009, so include some people taking older and less effective HIV treatments.

Most of those in the study (85%) are men, including around 40% who are gay men. Around 20% have a history of injecting drugs and 20% have hepatitis C.

The researchers give figures for the proportion of people who have different cancers by the age of 75. The two cancers which most commonly affect people with HIV are:

• Non-Hodgkin lymphoma (a cancer of the lymph nodes and lymphatic system) – 4.5% of people with HIV have this by the age of 75, versus 0.7% of HIV-negative people.      
• Kaposi’s sarcoma (a cancer which can cause skin lesions) – 4.4%, versus 0.01% of HIV-negative people.

People with HIV are vulnerable to the infections which cause these cancers when their immune system is weakened. Beginning HIV treatment early is the best way to avoid them – and helps with other cancers too. The risk of these two cancers has declined since the earlier years of the epidemic, but rates are still far higher than in the general population.

The third most common cancer is:

• Lung cancer – 3.4% in people with HIV, versus 2.8% in HIV-negative people.

The main cause of lung cancer is smoking. Surveys show that more people with HIV smoke than in the general population – the researchers say that services to help people with HIV stop smoking are a priority. They also recommend lung cancer screening.

The next two cancers are:

• Anal cancer – 1.5% versus 0.05%
• Liver cancer – 1.1% versus 0.4%.

The risk of these has increased in recent years. This is because people with HIV are living longer and so have a greater risk of developing diseases other than HIV. Also, people living with HIV have high rates of the infections which cause these cancers – human papillomavirus (HPV), hepatitis B and hepatitis C. Vaccination and treatment for these infections can help prevent cancer.

Rates of other cancers were not always higher in people living with HIV:

• Bowel cancer – 1.0% versus 1.5%.
• Hodgkin lymphoma (another cancer of the lymph nodes and lymphatic system) – 0.9% versus 0.09%.
• Mouth and throat cancer – 0.8% versus 0.8%.
• Melanoma skin cancer – 0.5% versus 0.6%.

The researchers think that three things need to be prioritised so that fewer people with HIV develop cancers – early HIV treatment, smoking cessation and lung cancer screening.

Stigma and disclosure in Ireland

In-depth interviews with gay men living with HIV in Dublin starkly reveal the extent of HIV stigma in the gay community there.

Among these interviewees, not disclosing HIV status to casual sexual partners was common. This served as self-protection – the men expected to be gossiped about and rejected by sexual partners if they disclosed their HIV status. They reported highly stigmatising language such as ‘slut’, ‘leper’, ‘criminal’ and ‘AIDS-riddled whore’. These terms portray people living with HIV as promiscuous and socially deviant.

Disturbingly, several of the HIV-positive interviewees seemed to have a similar attitude themselves. They were sometimes judgemental about other men living with HIV and appeared to avoid having them as friends or sexual partners. Hardly any interviewees had a support network that included other people living with HIV.

The researcher thinks that the HIV stigma in Ireland is so strong that many of his interviewees had come to believe the things that other people say about HIV. Some people call this ‘internalised stigma’ or ‘self stigma’.  

For more information, you may find our booklet ‘HIV, stigma & discrimination’ helpful. The booklet explains what stigma and discrimination are, makes some suggestions about disclosing HIV status and gives information about your legal rights in the UK.

When is HIV transmitted?

Swiss researchers have tried to get a better understanding of situations in which there is a risk of HIV being passed on. To do this, they’ve looked at the genetic characteristics of stored blood samples of people living with HIV. Using a technique called phylogenetic analysis, they looked for pairs of people whose HIV appears to be closely related. It’s likely (but not certain) that HIV was passed from one of these people to the other.

After looking at the blood samples of over 11,000 people (around a quarter of all people with HIV in Switzerland), they identified several hundred samples which were closely related. Using one definition of ‘closely related’, 378 pairs were identified. Using a stricter definition, 71 were.

It’s worth noting that this method has limitations. Over 90% of samples couldn’t be linked to another, meaning that the researchers have no idea where their HIV infection came from. It could be from a Swiss person with diagnosed HIV whose blood sample wasn’t included in the study, or from a person whose HIV remains undiagnosed, or from someone outside the country.

For around half the samples, the researchers knew both roughly when the person became HIV-positive and when they were diagnosed.

They found that just under half (44%) of transmission pairs included someone who had themselves been HIV positive for less than a year. This confirms several other studies which have found that people with recent HIV infection (who generally don’t know that they have HIV) are responsible for a disproportionate number of HIV transmissions.

Looking at the HIV transmission which happened later on in a person’s infection, the researchers examined 121 cases:

• 67 involved a person not taking HIV treatment.

• 18 involved someone who had only recently started taking HIV treatment and who did not yet have an undetectable viral load.

• 16 involved someone who had started – and then stopped – taking HIV treatment.

• Data were missing or unclear for the other 20 cases.

This shows the success of HIV treatment in preventing HIV from being passed on. But it also highlights two periods of vulnerability when transmission can happen. Firstly, in the first few months of taking treatment, before it has fully got HIV under control. Secondly, if people take a break from HIV treatment.

Resistance to integrase inhibitors

There’s some good news about one of the newer classes of anti-HIV drugs, integrase inhibitors. Drugs in this class are raltegravir (Isentress), dolutegravir (Tivicay) and elvitegravir (Vitekta, also included in the Stribild tablet).

One concern about anti-HIV drugs is resistance. When someone misses doses of their HIV treatment, their HIV can become resistant to some of the drugs they are taking.

This does happen with integrase inhibitors.

Another concern is the sexual transmission of resistant virus. In other words, if the person who has drug-resistant HIV passes HIV on to another person, the second person may have virus which is resistant to some anti-HIV drugs – before they have ever taken HIV treatment themselves.

The good news is that this doesn’t appear to be happening with integrase inhibitors. It seems that HIV which is resistant to integrase inhibitors does not easily replicate and soon dies out.

There’s more information about drug resistance in NAM’s booklet ‘Taking your HIV treatment’.