HIV Weekly - 30th January 2013

HIV and life expectancy

There’s been a lot of good news about life expectancy for people with HIV and on treatment in the last few years. The latest UK research shows that prognosis is now near normal for those with a CD4 cell count above 350 – the current threshold for starting HIV treatment.

Now research from Switzerland has found that death rates in people with HIV are falling, and that fewer people are dying of HIV-related causes.

The introduction of effective HIV treatment caused a significant fall in deaths due to HIV and AIDS. But mortality rates were still higher in people with HIV, and people with HIV were still dying younger.

The Swiss researchers looked at death rates and causes of death in 16,134 people with HIV, and receiving care, between 1988 and 2010.

Before combination HIV treatment was available, 78% of deaths were thought to be due to AIDS – this fell to 15% by 2005-10. Although AIDS was one of the most frequent causes of death between 2005 and 2009 (at 16%), 19% of deaths were due to non-AIDS-related cancers and 15% to liver failure.

Of the 459 people who died in that period (5%), 45% also had hepatitis C and 11% hepatitis B. An increased risk of death was also linked to injecting drug use, smoking, having diabetes, and interrupting HIV treatment.

The researchers suggest that many of the causes of death were connected to risk factors that could be reduced, and emphasised the importance of these being addressed by both HIV specialist services and primary health care (such as GPs).

Recently, other research has also shown that factors other than HIV can be more significant in causing illness and death in people living with HIV, such as smoking.

Taking HIV treatment carefully, as prescribed, is an important part of staying well. Find out more in our Adherence & resistance booklet.

HIV treatment as prevention

There’s now very good evidence that HIV treatment that suppresses viral load to undetectable levels significantly reduces the risk of HIV transmission.

In 2008, a group of HIV doctors in Switzerland issued what has come to be known as the Swiss statement. This said that in certain specific circumstances people taking effective HIV treatment should not be considered sexually infectious.

The Swiss statement caused a lot of debate, but results from a clinical trial in 2011 confirmed that the risk of HIV transmission was reduced by 96% in serodiscordant couples if the HIV-positive partner was on effective HIV treatment.

Now, the UK HIV doctors’ organisation, BHIVA, and the Expert Advisory Group on AIDS (EAGA) have published a position statement on the use of HIV treatment as prevention.

The statement provides guidance for healthcare professionals advising people living with HIV. It states that, provided certain conditions are met, the risk of HIV transmission is “extremely low”. These conditions are:

• Neither partner has a sexually transmitted infection (STI).
• The partner with HIV has had an undetectable viral load for at least six months.
• They have their viral load measured every three to four months and regular sexual health screening.

The statement recommends that healthcare staff discuss the option of starting HIV treatment as a prevention tool. Although there aren’t research findings on the effectiveness of condoms that compare exactly, it now seems that ‘treatment as prevention’ is as effective as condom use in preventing HIV.

However, the statement also says that no single prevention method is completely safe – and that condoms can prevent other sexually transmitted infections (STIs).

HIV treatment: safety and side-effects

There are now more than 20 anti-HIV drugs available. The drugs most often used in the UK today are very safe. Most of the side-effects they cause are mild and reduce or go away altogether over time.

Two drugs recommended by the World Health Organization (WHO) as part of a combination for people starting HIV treatment for the first time are efavirenz (Sustiva, also in the combination pill Atripla) and nevirapine (Viramune and Viramune prolonged-release). The WHO considered that they were equally effective but were linked to different types of side-effects.

Now there is some evidence that efavirenz may be a more effective and safer drug.

Researchers analysed 34 studies looking at the use of the two drugs in adults and children. They wanted to see how many people stopped treatment with each of the drugs, and how often they each caused side-effects.

People taking nevirapine were twice as likely to stop treatment with the drug because of side-effects (9%), compared to those taking efavirenz (6%).

Those taking nevirapine were more likely to develop liver and skin problems, including hypersensitivity (allergic) reactions. People taking efavirenz were more likely to experience side-effects affecting their central nervous system (the brain and spinal cord).

The researchers suggest that efavirenz should become the preferred drug for people starting HIV treatment.

UK guidelines on HIV treatment recommend efavirenz as part of the preferred first-line treatment combination. But they recognise that evidence shows nevirapine is an acceptable alternative and will be a better choice for some people.

You can find out more about all the anti-HIV drugs commonly used in the UK in our booklet Anti-HIV drugs.

HIV/hepatitis co-infection and bone density

Previous research has shown that problems with bone health are more common in people with HIV. Infection with HIV can reduce bone density, as can HIV treatment.

The problem has been especially associated with a class of anti-HIV drugs called protease inhibitors and with tenofovir (Viread, also in the combination pills Truvada, Atripla and Eviplera), which is an anti-HIV drug from the NtRTI (nucleotide reverse transcriptase inhibitor) class.

Bone loss is also more common in women who have been through the menopause, because of hormonal changes.

Now researchers have found that co-infection with HIV and hepatitis B or hepatitis C is a risk factor for reduced bone mineral density in women.  

The study aim was to explore factors affecting bone mineral density and determine the impact co-infection with hepatitis B or hepatitis C might have.

Older age and having a low body mass index (BMI) were associated with low bone mineral density for men, but co-infection with hepatitis was not. There was an association with co-infection for women, however, along with older age and a low BMI.

The researchers suggest that HIV care should take these factors into account, offering preventive treatment and care where necessary. Routine HIV care in the UK includes monitoring of bone health, especially if you are aged 50 or over.

Although the causes of reduced bone density are not well understood, there are changes you can make which can improve bone health. Exercise, eating a healthy diet and making healthy lifestyle changes such as stopping smoking can all improve bone density.