HIV treatment – changing treatment
Modern HIV treatment is very effective, easy to take, and usually causes only mild side-effects.
A preferred combination for people starting antiretroviral therapy is Atripla.
But like all drugs, it can cause side-effects. Notably efavirenz has been associated with central nervous system (CNS) side-effects, such as mood and sleep problems including anxiety, depression, vivid dreams or insomnia.
These side-effects generally occur in the first few weeks of treatment, and often they lessen or go away completely over time.
But for some people these side-effects can be particularly difficult to cope with, or persistent, and mean that they need to change treatment.
Researchers at London’s Chelsea and Westminster Hospital looked at the notes of 472 people who started treatment with Atripla.
They found that the drug was highly effective – after a year of therapy 98% of people had an undetectable viral load.
But, overall, 19% of patients changed treatment within a year. For nearly three-quarters of those who changed, the reason was the CNS side-effects that are associated with efavirenz.
People appear to have put up with these side-effects for quite some time before changing treatment; almost half switched to an alternative combination between three and twelve months after starting Atripla.
All medicines can cause side-effects, but if you are experiencing side-effects caused by your HIV treatment it’s a good idea to speak to your doctor or another member of your healthcare team. It’s almost always possible to do something about side-effects.
Under changes to prescribing guidelines in London, Atripla is no longer the preferred first choice for people starting treatment. People already taking Atripla will not need to change unless there is a clinical reason to do so.
You can find out more about dealing with side-effects in our Side-effects booklet.
HIV treatment – resistance
The same study demonstrated that there has also been a steep decline in the percentage of people with virus which is resistant to drugs in the three main classes of antiretrovirals – nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors.
HIV can become resistant to the drugs used to treat it, meaning they can no longer effectively suppress viral load.
Many older antiretroviral drugs were not as effective, and were also difficult to take or caused serious side-effects.
This was especially the case with the first generation of protease inhibitors.
But there have been major improvements in HIV treatment options over the last ten years or so. These include the development of ritonavir-boosted protease inhibitors and the introduction of some completely new classes of antiretroviral drug. Indeed, an undetectable viral load is now the aim of HIV treatment for nearly all patients.
The latest study shows the impact these improvements in treatment options are having.
Researchers looked at the type of drug resistance present in almost 70,000 blood samples sent for resistance testing between 2003 and 2010.
The proportion of samples with resistance to a protease inhibitor dropped from 52% in 2003 to 26% in 2010.
There was also a steep fall in the percentage of samples with triple-class resistance – from 29 to 11%.
You should have a resistance test when you are first diagnosed with HIV, and again when you start HIV treatment. A repeat test should be performed if your viral load then increases to detectable levels. The results of a resistance test can help you and your doctor choose the most suitable combination of anti-HIV drugs.
Mother-to-child transmission of HIV
Researchers from City University in London found that a quarter of women presented after 17 weeks of pregnancy and that 5% accessed care after week 28.
The rate of late presentation in HIV-positive women was twice that seen in women who were HIV-negative.
Late presentation was common among women whose HIV was undiagnosed (58%), and also for women aware of their HIV status (47%).
HIV can be passed on from a mother to her baby during pregnancy, childbirth and breastfeeding. With the right treatment and care the risk of mother-to-child HIV transmission is reduced to below 1%.
“Women initiating antenatal care beyond 13 weeks miss the opportunity of early screening for HIV (if they have not yet been diagnosed) and other conditions, and have less time to engage with HIV services,” the researchers commented. “This may have an adverse effect on obstetric and maternal health outcomes.”
For evidence-based information, visit the Prevention of mother-to-child transmission section of our HIV treatments directory.
Viral load and infectiousness
Viral load is featuring in the safer sex discussions of gay men.
One of the hottest topics in HIV prevention is the impact of successful HIV treatment on infectiousness.
Studies conducted in largely heterosexual populations suggest treatment that lowers blood viral load to undetectable levels reduces the risk of HIV transmission by approximately 96%.
The small study involved 120 men. Overall, 38% said they had decided to have unprotected anal sex with an HIV-negative partner because their viral load was undetectable.
“Viral sorting as a risk reduction strategy is consciously practised relatively frequently among HIV-positive MSM [men who have sex with men],” the researchers concluded.
However, they cautioned “since most of the available data on viral load and HIV transmission risk is derived from studies on heterosexuals, future investigation should provide evidence on the effectiveness of viral sorting as an HIV risk reduction strategy in lowering HIV transmission among MSM.”
Separate US research also showed that some HIV-negative gay men were basing safer sex decisions on knowledge of their HIV-positive partner’s viral load.
Viral load was discussed in 70% of steady relationships where the HIV-positive partner had disclosed. Approximately 50% of couples subsequently had unprotected sex.
In casual encounters where HIV status had been disclosed, viral load was discussed in about 50% of cases, leading to unprotected sex in around 50% of encounters.
However, the researchers pointed out that only 7% of HIV-positive men enrolled in their study had disclosed their status to their sexual partners.
HIV and hepatitis C – treatment side-effects
Earlier research conducted in people who only had hepatitis C showed that this level of coffee consumption increased the success rate of hepatitis C therapy.
Large numbers of patients with HIV also have hepatitis C.
Treatment is available for hepatitis C, but it doesn’t always work and can cause unpleasant side-effects.
It had previously been established that drinking large amounts of coffee is associated with lower levels of liver enzymes and slower progression of pre-existing liver disease.
US researchers found that the chances of hepatitis C therapy working were increased by about 80% in people who drank three or more cups of coffee each day.
Now French researchers have found that HIV-positive people co-infected with hepatitis C were much less likely to report side-effects of hepatitis C treatment if they drank three or more cups of coffee each day.
The researchers think that this could partly be because caffeine helped combat the fatigue and lack of alertness often reported by people undergoing hepatitis C therapy.
HIV and prisoners – brief periods in jail worsen outcomes
The study involved HIV-positive injecting drug users.
It found that, for people taking HIV treatment, spending between seven and 30 days in prison significantly increased the risk of viral load becoming detectable.
They think this is because brief periods of incarceration were associated with interruptions in HIV treatment.
“Our data show that incarceration is a strong marker of increased vulnerability to virologic failure for injecting drug users using HIV treatment,” comment the investigators. “Our…findings highlight that improved strategies to indentify and successfully link HIV-infected inmates to appropriate HIV care are urgently needed.”
It said that: “The prison system is an environment of real risk for acquiring HIV.”
The peers added that the “need to increase the uptake of testing is of particular importance in prisons given the relatively high prevalence of HIV.”
Standards of HIV treatment and care in UK prisons are meant to be the same as those provided in the community. But in practice this isn’t always the case, and the quality of treatment varies considerably.
The report recommends that prisoners should be offered opt-out HIV tests on a routine basis upon entering the prison system. They should also have confidential access to condoms, lubricant and dental dams. They also want to see guidelines drawn up covering prevention, testing and treatment in prisons.