Very early HIV infection
New research shows that a severe HIV seroconversion illness is associated with faster HIV disease progression. The study found that people who had very low CD4 cell counts or who experienced especially severe symptoms during this earliest phase of HIV infection experienced more rapid disease progression than people who had milder symptoms. The doctors who undertook the research suggest that people with a severe seroconversion illness may benefit from early antiretroviral therapy.
The initial phase of infection with HIV is called primary HIV infection. HIV replication increases to very high levels and the body develops antibodies in response to HIV. This is usually accompanied by symptoms – a seroconversion illness. They are often flu-like and last for around one to two weeks. In some people, the symptoms are so mild that they pass unnoticed.
However, for others the symptoms of seroconversion illness are severe. It was not clear whether the severity of symptoms during primary HIV infection is associated with subsequent disease progression.
Researchers therefore monitored outcomes in over 1100 people with a known date of HIV seroconversion.
They were classified as having a severe seroconversion illness if they developed illnesses including pneumonia, bronchitis, thrush in the mouth or throat or a low platelet count within six months of acquiring HIV. A single CD4 cell count below 350 or two counts below 500 were also used to define a severe illness.
A severe illness was observed in 15% of people in the study, and the presence of severe clinical symptoms doubled the risk of subsequent progression to AIDS or death. Overall, people with severe symptoms developed AIDS two years earlier than people with milder symptoms (6 vs 8 years).
Similarly, people with immune suppression during primary HIV infection also had faster disease progression than people with CD4 cell counts above 350 or 500.
The researchers suggest that people with a low CD4 cell count and/or severe symptoms during primary HIV infection could be candidates for early antiretroviral therapy. But they call for more research to evaluate the benefits of treatment during primary infection.
The SPARTAC trial was set up to investigate whether taking HIV treatment for a short time, soon after infection, would slow down the damage caused by HIV. In 2012, we worked with the SPARTAC trial team in the UK to produce an illustrated leaflet called Very recent infection. You can find out more about that project in the NAM blog, and view or download the leaflet from www.aidsmap.com/basics
Antiretroviral treatment for women
The risk of virologic failure was higher with atazanavir/ritonavir treatment.
Little is known about the difference in antiretroviral treatment outcomes between men and women. This is an important knowledge gap, and an increasing proportion of HIV infections are in women.
Researchers in the US therefore analysed outcomes in 1857 people living with HIV – 322 of whom were women – who started first-line HIV treatment based on efavirenz or atazanavir/ritonavir. These drugs were taken in combination with either Truvada (FTC/tenofovir) or Kivexa (3TC/abacavir).
Treatment failure was defined as a viral load above 1000 copies/ml after 16 weeks of treatment or a viral load above 200 copies/ml after six months.
Overall, women taking atazanavir/ritonavir had an increased risk of treatment failure compared to women taking efavirenz.
The researchers admit that this finding was unexpected, and call for randomised studies involving large numbers of women comparing the effectiveness of these two drugs.
It’s important to get this question clarified. Atazanavir/ritonavir is sometimes preferred over efavirenz for women who are pregnant or thinking of becoming pregnant. This is because efavirenz has been associated with a theoretical risk of certain birth abnormalities, although a meta-analysis found no increased risk of overall birth defects among women who took efavirenz.
Thinking about starting HIV treatment? Our online tool, Get set for HIV treatment, can help you decide whether you are ready to start. It asks some (anonymous) questions and then produces a personalised factsheet for you, based on the answers you have given. You could use it to prepare for a conversation about HIV treatment with your doctor: www.aidsmap.com/getset
Anal cancer
Successful antiretroviral therapy may reduce the risk of anal cancer for men living with HIV.
New research shows that men who were highly adherent to their HIV therapy (were taking it as prescribed) and had an undetectable viral load were less likely to have anal infection with the strains of human papillomavirus (HPV) associated with a high risk of cancerous cell changes.
Rates of anal cancer are much higher in HIV-positive gay men and other men who have sex with men (MSM) than any other group. Persistent infection with high-risk HPV types can lead to pre-cancerous cell changes.
Researchers in the US wanted to see which factors were associated with anal HPV infection in a cohort of 1262 HIV-positive and HIV-negative MSM.
Almost half the men (46%) were living with HIV and overall 80% had anal infection with at least one HPV type. Prevalence was higher in men with HIV than HIV-negative men (91 vs 71%), and men with HIV were also more likely to have infection with the strains of HPV most associated with cancerous cells changes – HPV 16/18 (31 vs 20%).
For men with HIV, complete adherence to antiretroviral therapy and maintaining an undetectable viral load were protective against infection with high-risk HPV types. A high CD4 cell count also reduced the risk of infection with the strains of HPV most associated with cancerous cell changes in the anus.
Having a higher number of receptive anal sex partners was associated with an increased risk of infection with certain HPV types. Smoking was another risk factor.
The researchers believe their findings have important implications for the prevention of anal HPV infection in men living with HIV: “Long-term mutual monogamy and smoking cessation, generally, and [combination antiretroviral therapy]-adherence that promotes (HIV) viremia [viral load] control and prevents immunosuppression, specifically among HIV-infected MSM are important prevention strategies for HPV infections that are relevant to anal cancer.”
This research was published in the open-access journal PLOS ONE, so as well as reading the news report on aidsmap.com, you can read the journal article in full, free, on the PLOS ONE website.
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