HIV treatment as prevention

There’s a lot of debate about the infectiousness of people taking HIV treatment who have an undetectable viral load.

HIV treatment lowers viral load in the blood and other body fluids, including genital fluids.

In January 2008 some senior 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.

For this to be the case, the person must:

• Have had an undetectable viral load for at least six months.
• Take their treatment properly.
• Be free of other sexually transmitted infections.

The Swiss doctors based their statement on studies conducted in Africa which showed that there were no HIV transmissions in heterosexual couples when the HIV-positive partner was taking treatment and had an undetectable or low viral load.

There is a consensus that taking HIV treatment and having an undetectable viral load does reduce the risk of passing on the infection to others. However, most researchers think that there’s still a small risk. In addition, much of the available research has focused on vaginal sex in heterosexual couples and may not reflect the transmission risk from anal sex.

Now Swiss investigators have found that people with HIV are more likely to report unprotected sex with a stable HIV-negative partner if they are taking antiretroviral treatment and have an undetectable viral load.

After the publication of the Swiss statement, there was a big increase in the number of HIV-positive people who reported using their viral load to guide decisions about condom use with their main HIV-negative partner.

However, the researchers note that this increase in unprotected sex was not accompanied by an increase in the number of people being infected with HIV.

Using illicit drugs and heavy alcohol use were also associated with unprotected sex.

But some doctors are concerned that people are using viral load to guide decisions about condom use.

An editorial accompanied the latest Swiss research. The author said there are still a lot of unanswered questions about the impact of treatment on infectiousness.

The Clinical Infectious Diseases journal article is available here and the editorial is available here.

Side-effects of HIV treatment –
bone loss

Thanks to HIV treatment, many people with the virus can expect to live a long and healthy life.

But like all medicines, those used to treat HIV can cause side-effects.

There’s currently a lot of interest in the impact of treatment on the health of bones.

HIV itself can cause a loss of bone density – this can increase the risk of fractures. Some research has also shown that taking some anti-HIV drugs can reduce bone density.

Now a Spanish study has shown that 48% of HIV-positive patients have thinning bones, and in 23% this is serious enough to involve a risk of fractures.

Their research involved 671 patients. Bone density was assessed at least once using a type of body scan.

In addition, 391 patients had at least one other scan. The results of these showed that bone density worsened in 28% of patients.

Traditional factors for bone loss include older age and low body weight. The researchers found that these were associated with bone loss in their patients.

But they also found that current use of protease inhibitors, as well as length of treatment with a protease inhibitor or tenofovir (Viread, also in the combination pills Truvada and Atripla) were associated with reduced bone density.

The researchers believe that people taking HIV treatment should have their bone density monitored regularly.

This is because bone density can be improved with a good diet, by stopping smoking, and by certain types of exercise.

For more information on HIV-related bone loss, you can read our recent feature article Skeleton key on our website.

Side-effects of HIV treatment – treatment for facial wasting

The older anti-HIV drugs d4T (stavudine, Zerit) and AZT (zidovudine, Retrovir, also in the combination pills Combivir and Trizivir) can cause a side-effect known as lipoatrophy.

This involves loss of fat from the legs, buttocks and face.

These drugs are no longer recommended for routine, long-term use in high-income countries, and switching to other HIV drugs has been associated with very slow recovery of fat in the limbs.

But often the only treatment for facial fat loss is cosmetic surgery.

Doctors have reviewed studies looking at this treatment.

They found that patients’ suitability for surgery was assessed either according to the severity of fat loss, or because of its impact on their emotional and mental health.

Fat transfer was the researchers’ preferred treatment option for severe fat loss. For moderate or mild fat loss, they recommended the use of a biodegradable filler such as polylactic acid.

They found that complications did occur, they were quite rare and that side-effects were mild and went away with time.

For more information on side-effects, visit our website. Older anti-HIV drugs are more common in resource-limited settings. Visit our website for a clinical review of body-fat changes in people with HIV, written for healthcare professionals in resource-limited settings.