When to start HIV treatment

Not starting HIV treatment until CD4 cell count has fallen below the 350 threshold is associated with an important early warning sign of cardiovascular disease, new research shows.

US doctors found that starting HIV treatment below 350 cells/mm³ was associated with poorer endothelial function – blood flow through the arteries.

Previous research has shown that the risk of cardiovascular disease is increased for people with HIV. However, there’s uncertainty about the exact causes.

Traditional risk factors are important. But the side-effects of some anti-HIV drugs may increase the long-term risk of diseases such as heart attack and stroke.

However, there’s now a lot of evidence that the damage caused by HIV is also an important factor.

In this study, doctors compared endothelial function in people who started HIV therapy when their CD4 cell count was below 350 with those who started treatment at a higher CD4 cell count.

They found that endothelial function was significantly poorer in the people who started HIV therapy at lower CD4 cell counts.

They emphasise that this had a similar impact to having diabetes, smoking, or existing cardiovascular disease.

Current UK guidelines about the use of HIV treatment recommend that, as is currently recommended for most people with HIV, people with a risk of cardiovascular disease should start treatment when their CD4 cell count is around 350. The authors concluded there was not enough evidence to say that having risk factors for cardiovascular disease should mean a different approach to treatment, such as starting earlier.

The guidelines recommend that people with HIV should have their risk of cardiovascular disease assessed every year as part of their routine care. This allows problems to be spotted early so appropriate treatment can be offered.

If you smoke, stopping smoking is a really important step you can take to look after your health. Eating a healthy diet, taking regular exercise and not drinking too much alcohol are all ways of reducing your risk of cardiovascular disease. For an easy overview, take a look at our illustrated leaflets Seven ways to look after your health and A healthy weight.

Diabetes and kidney disease

Diabetes is an important risk factor for cardiovascular disease. But it can also cause illness in its own right, especially kidney disease.

Now doctors have found that it is associated with an especially high risk of kidney disease for people with HIV.

Kidney disease is an increasingly important cause of serious illness and death in people with HIV. Doctors wanted to see if diabetes was a possible cause.

They therefore looked at the medical records of over 30,000 people and compared their risk of kidney disease according to whether they had HIV, diabetes, or both.

People without either HIV or diabetes had the lowest risk of kidney disease and those with both HIV and diabetes had the highest risk.

In addition to diabetes, risk factors for kidney disease for HIV-positive patients included a high viral load, higher blood pressure and hepatitis C co-infection.

The health of your kidneys and your risk of diabetes should both be monitored as part of your routine HIV care. For more information, visit our feature HIV and the kidneys.

HIV treatment as prevention: gay men

The use of HIV treatment in prevention is a hot topic at the moment.

Treatment that suppresses viral load to undetectable levels has been shown to reduce the risk of sexual transmission of HIV by up to 96%.

The research looking at the impact of treatment on infectiousness has mostly been conducted in heterosexual couples.

But Danish investigators believe they have found evidence that the increased use of treatment is helping to slow the spread of HIV in gay men.

They looked at rates of new HIV diagnoses between 1995 and 2009.

Effective HIV treatment first became available in the late 1990s and this was accompanied by a small fall in the number of new diagnoses. They then increased slightly, but stabilised after 2005.

The stabilising of the epidemic was despite big increases in the proportion of gay men reporting risky sex, and a massive increase in the number of syphilis diagnoses.

The researchers therefore think that it is HIV treatment that is helping to control the epidemic in gay men.

HIV treatment as prevention: conception

In related news, draft UK guidelines on fertility treatment say that sperm washing is no safer than effective HIV treatment together with 'timed conception'.

Sperm washing is a technique designed to enable couples where the man is HIV-positive and the woman HIV-negative (often called ‘serodiscordant’ couples) to conceive a baby without the risk of HIV transmission.

It involves the removal of sperm from seminal fluid (where HIV is contained), which is then used for artificial insemination.

It is very safe – it has never led to the transmission of HIV. But it doesn’t always result in pregnancy, can be expensive and is only offered by a few specialist clinics.

The new draft guidelines are produced by the National Institute for Health and Clinical Excellence (NICE) and say that sperm washing is no safer than effective HIV treatment and timed intercourse (where sex without condoms is limited to days when the woman is ovulating).

For this to be the case, the following conditions need to be met:

• The man is taking HIV treatment.
• His viral load is undetectable.
• Neither partner has a sexually transmitted infection.
• Unprotected sex should be limited to the days the woman is fertile.

If these conditions are not met, or if there is still concern about the risk of HIV transmission, then sperm washing may still be available.

For more information, visit our online Preventing HIV resource, which contains a section on HIV treatment as prevention.