HIV update - 8th July 2015

Starting treatment soon especially important for people over 45

The benefit of starting HIV treatment promptly has been a major theme of HIV research in recent weeks.

Six weeks ago, a large and important study conclusively demonstrated that by beginning HIV treatment early – when their CD4 cell counts are still high – people living with HIV can significantly reduce their risk of developing AIDS, other serious illnesses unrelated to AIDS, and dying. As a result, British doctors proposed two weeks ago that HIV treatment should be recommended to all people living with HIV, whatever their CD4 count.

Now, an analysis has found that delaying HIV treatment may have especially serious consequences for middle-aged and elderly HIV-positive people. Researchers looked at data on around 3500 Americans taking HIV treatment, with a particular concern for those people who died within ten years of starting treatment. This includes deaths from any cause, not necessarily related to HIV.

As expected, people with lower CD4 counts (indicating a weakened immune system) had poorer outcomes: 11% of those starting treatment with a CD4 count above 500 cells/mm³ died, compared to 12% of those with a CD4 count between 350 and 500, and 14% of those with a CD4 count of less than 200.

But this relationship was especially stark for those aged 45 to 64: 19% of those starting treatment with a CD4 count above 500 died, compared to 22% of those who started between 350 to 500, and 28% of those who started with less than 200.

This suggests that starting treatment as soon as possible is especially important for people over the age of 45.

Who should get hepatitis C treatment?

As HIV Update has reported several times in the past few years, the new drugs for hepatitis C are a significant improvement on those that were previously available. But pharmaceutical companies are charging extremely high prices for them, which is forcing health services to make difficult choices about which patients should be prioritised to receive the new drugs.

Frequently only those people with the most advanced liver disease are able to get the new drugs. It can be difficult for people who are not yet very sick to get the treatment that could prevent their illness from getting any worse.

In this context, doctors need to prove that certain groups of patients should receive treatment more urgently than others. One way of doing this is to show the consequences of leaving people without treatment.

A group of researchers therefore looked at the risk of death, because of liver disease, in almost 4000 European people who had both HIV and hepatitis C. These people hadn’t received hepatitis C treatment.

The researchers looked at this risk according to the degree of damage that had already occurred to the liver – little or no damage; fibrosis (moderate scarring); or cirrhosis (more serious scarring).

Every year, 1 in 100 people died of liver disease. But compared to people with little or no fibrosis, this risk was more than doubled in people with fibrosis. And the risk was six-times greater for people with cirrhosis.

The doctors therefore argue that any person living with HIV who has either fibrosis or cirrhosis should be prioritised for treatment with the new drugs.

While this would limit treatment to a minority of patients, it would be less restrictive than current NHS England policies – the drugs only go to some people with cirrhosis, the more advanced form of scarring.

The research also found that having a low CD4 count raised the risk of liver disease and death. HIV treatment improves liver-related outcomes, so anyone with HIV and hepatitis C co-infection should start HIV treatment as soon as possible, the researchers recommend.

Treatment reduces stigma

Surveys from African countries suggest that the greater availability of HIV treatment is slowly reducing levels of HIV stigma in the general population.

Since 2003, researchers in 18 African countries have been asking people the same questions about HIV and AIDS. These include whether people would be willing to care for a family member who was ill with AIDS and whether a teacher living with HIV should be allowed to continue teaching.

Levels of stigma remain high, but have gone down as HIV treatment has become more widely available. The greatest reductions have been seen in countries where larger numbers of people are living with HIV and in countries where more people are taking HIV treatment.

There are many sources of HIV stigma, including fear of a serious illness, anxiety about it being passed on, disapproving attitudes towards sex, and stereotypes about people thought to be more likely to have HIV.

The study suggests that providing HIV treatment can alter people’s view of HIV as a life-threatening illness. But it can’t deal with all the sources of stigma.

And a separate study from Uganda suggests that the roll-out of antiretroviral therapy has led to more HIV-positive people discussing their HIV status with their spouses.

Focusing on couples who were married or lived together, the researchers measured rates of HIV status disclosure, both before and after HIV treatment became available in a rural area in 2004.

The proportion of men disclosing increased from 63% to 78%. The proportion of women who did so went up from 55% to 73%. Individuals taking treatment themselves were especially likely to talk about their HIV status.