HIV Weekly - 4th September 2013

HIV treatment: the impact of a detectable viral load

Viral load is the term used to describe the amount of HIV in the blood. The aim of HIV treatment is an ‘undetectable’ viral load – that is, a level so low that it cannot be detected in a blood sample by a viral load test. (Tests used most commonly in the UK have a lower limit of detection of around 50 copies/ml, and if your viral load is below 50, it is usually said to be undetectable.)

For people on HIV treatment, having a higher viral load can be an indication that their current combination of anti-HIV drugs is not working as well as it should. It can also increase the risk of resistance developing to those drugs, and possibly to other drugs in the same class. However, not everyone on HIV treatment achieves and maintains an undetectable viral load. It has not been clear what the effect of having a very low – but detectable – viral load over the longer term would be.

Now researchers in Canada have found that having a constantly detectable viral load over a period of time is linked to an increased risk of that treatment combination not working. Even if viral load was still very low – between 50 and 199 copies/ml – people with viral loads at this level over a period of six months had twice the risk of treatment ‘failure’, compared to people whose viral loads were always undetectable.

Results were similar when the investigators looked at the persistence of low-level, but detectable, viral loads for nine and twelve months.

However, the research didn’t look at whether there were any differences in the effect of low-level detectable viral loads depending on which anti-HIV drugs people were on.

The authors suggest their findings confirm the importance of acting promptly if viral load is detectable over a number of months. This might include looking at adherence levels, possible interactions with other medications and closer monitoring, as well as possibly changing HIV treatment combinations.

Find out more in our CD4, viral load & other tests booklet, available in UK clinics and on our website at: www.aidsmap.com/booklets

HIV and hepatitis: risk of serious liver disease

Many people living with HIV also have hepatitis C (often referred to as a co-infection). Liver disease caused by hepatitis C is an important cause of serious illness and death in people with this co-infection, and it can progress quickly. Hepatitis C (HCV) can cause liver fibrosis (liver stiffening) and cirrhosis (scarring of the liver).

Spanish research has found that people with co-infection and advanced liver fibrosis can, very quickly, develop very serious liver disease (also called decompensated liver disease, because the liver can no longer compensate for the damage done to it and symptoms will start appearing), even though they do not have cirrhosis of the liver.

The researchers believe their findings have implications for HCV treatment strategies. They suggest that people with advanced fibrosis should be considered for early treatment with combinations based on newer, direct-acting drugs: telaprevir (Incivo) or boceprevir (Victrelis).

Only a small number of people with co-infection have their HCV cured with standard treatment for HCV, which consists of pegylated interferon and ribavirin, and even fewer people with more advanced fibrosis or compensated cirrhosis. Boceprevir and telaprevir are currently used chiefly in people who have cirrhosis and a high risk of liver decompensation. Other people, including those with advanced fibrosis, are often recommended to wait, as easier-to-take HCV drug combinations come into use.

This new research suggests that treatment with telaprevir and boceprevir should also be considered for people with advanced fibrosis, especially if they have a low platelet count. People who do not receive treatment should be closely monitored, using a liver-stiffness test called FibroScan.

One possible – though rare – consequence of serious liver disease is hepatocellular carcinoma (HCC), or liver cancer. Calculations used to measure the risk of developing HCC for people living with HIV, and who have liver cirrhosis, generally don’t reflect the impact of highly active antiretroviral treatment (HAART).

Spanish research, aiming to get a clearer picture of the rates and risk levels of HCC for people on HAART, found that there were relatively low levels of HCC amongst people with liver cirrhosis.

However, HCC was more common in people who had decompensated cirrhosis, compared to participants with compensated cirrhosis (whose liver could still function despite the damage to it).

Survival rates for people with liver cancer are low, with the most effective treatment being surgery to remove the cancer or a liver transplant. Studies have found that people with HIV can do as well after a liver transplant as those without HIV. However, this research showed that, for people whose HIV is well-controlled with treatment, the risk of developing HCC is low.

Treatment for HIV and hepatitis B co-infection

Some anti-HIV drugs are effective against both HIV and hepatitis B. A meta-analysis of 23 studies on treatment for hepatitis B and HIV co-infection has found that tenofovir (Viread, also in the fixed-dose combinations Truvada, Atripla and Eviplera) is the most effective hepatitis B treatment for people with HIV and HBV co-infection.

It was rare both for HBV viral load to rebound after becoming undetectable, and for people to develop resistance to tenofovir. Combining tenofovir with other drugs such as 3TC or FTC did not improve treatment response.

Interested in hepatitis and HIV? Visit our hepatitis topics pages for more resources, feature articles and news about hepatitis and HIV co-infection. We’re also working with ELPA, the European Liver Patients Association, on a hepatitis information website for patient advocates and professionals working in hepatitis in Europe – check it out at www.infohep.org

The impact of HIV globally and in the UK

The overall annual death rate from AIDS has fallen by 21% since 2006, the most recent study in the Global Burden of Disease (GBD) series shows. However, while some countries with large HIV epidemics have been able to reduce rates of death and illness significantly, there are huge variations between countries and regions.

The GBD study compiles causes of death and disability and calculates disability-adjusted life-years (DALYs) lost to health conditions.

HIV and AIDS ranks fifth in the conditions that cause illness and death internationally. HIV is responsible for 3.3% of all DALYs lost worldwide, though in high-prevalence countries such as South Africa it is responsible for up to 40% of DALYs lost. It is the number one cause of DALYs lost for women aged 25 to 45 and men aged 30 to 45.

The UK has seen a 63.5% fall in DALYs lost to HIV between 1990 and 2010.