Infectiousness: a clarification of HIV weekly, May 15 2013
In HIV weekly last week, we reported on a study where a low, but detectable, viral load (between 50 and 500 copies/ml) was associated with the presence of HIV in semen.
We referred to research conducted in heterosexual couples as showing that “antiretroviral therapy that reduces viral load in the blood to undetectable levels (below 50 copies/ml) reduces the risk of sexual transmission by 96%”. In fact, the study showed that the strategy of giving early antiretroviral therapy to the HIV positive partner in serodiscordant couples reduced the risk of HIV transmission by 96%. While most of the people taking treatment early in this study had an undetectable viral load, not all did.
For more detailed information on HIV transmission, visit our online resource HIV transmission and testing.
Treatment and care
It’s recommended that people living with HIV have regular check-ups at specialist HIV clinics. With the right treatment and care, the life expectancy for many people living with HIV in the UK, and countries with similar standards of care, is now excellent. In addition, antiretroviral treatment that suppresses viral load to undetectable levels substantially reduces the risk of HIV transmission to sexual partners.
However, some people diagnosed with HIV either never establish regular contact with healthcare services after their diagnosis or stop attending appointments after a time. People who don’t attend appointments are sometimes described as being ‘lost to follow-up’.
Social care workers in New York City were concerned about the high rate of people who were lost to follow-up. Approximately 45% of people with HIV in the city are not receiving regular care, and a third are lost to follow-up after connecting with HIV outpatient care.
Case workers identified and located 400 people who were confirmed as lost to follow-up between mid-2008 and the end of 2010.
Three-quarters of these individuals agreed to make a medical appointment. Over half (59%) were confirmed as returning to care and almost all had viral load and CD4 monitoring in the twelve months after re-establishing care.
This monitoring showed the importance of re-connecting many of these people with regular care. More than half had a CD4 cell count below 200, meaning they had a high risk of developing an AIDS-defining illness. Many were potentially infectious to their sexual partners: over half had a viral load above 10,000 copies/ml.
Feeling well was the main reason for people dropping out of care, although depression was another important reason.
Want to get the most out of your HIV clinic appointments? Try our online Talking points tool before you next see your doctor, to help you prepare: www.aidsmap.com/talking-points
HIV and hepatitis E
Hepatitis E is a significant cause of acute (short-term) liver disease, especially in poorer countries. Often it causes no or very mild symptoms and causes no long-term damage. Eating undercooked pork products is a recognised risk factor for infection with hepatitis E.
Hepatitis E can be more serious in people who have a weakened immune system. Doctors in Spain have reported two cases of hepatitis E infection in gay men with HIV, both of whom had a low CD4 cell count. Both men developed rapid liver cirrhosis after infection with hepatitis E.
For one man, consumption of homemade pork liver pâté was the likely source of the infection.
Treatment with ribavirin normalised liver function and eventually the infection was cleared. A short course of ribavirin can temporarily stop the virus reproducing, but it is not yet clear what makes up the most effective treatment regimen.
The doctors recommend that people with HIV who have a low CD4 cell count and unexplained changes in liver function should be screened for infection with hepatitis E.
Hepatitis C treatment after liver transplant
Doctors looked at outcomes in 112 people with HCV mono-infection (they did not also have HIV) who had undergone a liver transplant but still had chronic HCV infection.
They received treatment with pegylated interferon and ribavirin, plus an approved HCV protease inhibitor, usually telaprevir (Incivo or Incivek).
Two-thirds of patients had an undetectable hepatitis C viral load after four weeks of therapy, a good predictor of long-term outcomes.
Analysis of the outcomes for 43 people who completed treatment showed that 65% still had an undetectable HCV viral load four weeks after completing treatment.
However, side-effects were very common, and caused 11% of patients to discontinue treatment; 20% had such serious side-effects that they required hospitalisation.
People with serious HCV-related disease are in urgent need of the option of new treatments. This study shows that outcomes can be good, but with a high risk of serious side-effects.
Alcohol, drugs and sex
Research conducted among HIV-negative gay men in San Francisco has shown that the frequency and intensity of drug and alcohol use is associated with an increased risk of unprotected sex.
The research involved over 3000 men who were recruited between 2009 and 2012.
They were interviewed about their use of drugs and alcohol and their sexual behaviour.
Results showed that more frequent use of drugs and alcohol before or during sex was associated with an increased risk of reporting unprotected anal sex with a partner who was HIV positive or of unknown HIV status.
Use of a greater number of substances was also associated with risky sex.
“HIV risk was strongly associated with frequency of use and number of substances used before and during unprotected sex,” write the authors.
They believe their findings have public health implications and that gay men who use substances “may benefit from strategies that build self-efficacy and promote skills for explicit HIV-serostatus communications with partners”.
Editors' picks from other sources
Françoise Barré-Sinoussi: the HIV hunter
from Financial Times
Thirty years ago, Françoise Barré-Sinoussi found an unidentified virus in a patient with Aids – work which won her a Nobel Prize. She talks about the continuing battle with the disease and her hopes of one day seeing a cure.
As Hepatitis C Spreads, Scotland Steps In
from Wall Street Journal
Scotland is ignoring conventional wisdom and making a bold push to control hepatitis C. The country's taxpayer-funded health system is scrambling to find and treat infections, with a particular focus on current and former injection drug users, who account for about 90% of infections here.
Terrence Higgins Trust unveils It Starts With Me HIV campaign video
from PinkNews.co.uk
Terrence Higgins Trust (THT) has released a short video clip outlining the science behind It Starts With Me, HIV Prevention England’s new campaign for gay and bisexual men. The clip shows how a combination of testing, treatment and condoms would lead to a significant reduction in HIV transmissions within the gay community.