Frustration

My experiences of life with HIV over the last 16 or so years have, I hope, provided me with some insights that mean I do a better job here at NAM, and by and large, I leave most the office most days with a feeling that I’ve achieved something and with some sense of pleasure.

But it can also be a very taxing experience. I have to be honest, having HIV, even with effective treatment, makes life harder. I still have the occasional problems with my physical health. On top of this, the emotional and psychological strain of living with such a serious infection for so long has also taken its tool. It all got too much for me in mid March and I was forced to take a month off to recharge my batteries – thanks to Keith who added to his already heavy workload and took over HIV Weekly in my absence.

In my time away from the office, I did realise that one of the most stressful aspects of living with HIV and having HIV is having to interact with the prejudices and ignorance of others which all too often touches a raw nerve within me, leaving me angered, saddened and frustrated I am also left feeling that, no matter how hard I try to constructively channel these feelings into doing my job, I end up depleted.  But I take some comfort from knowing that providing accurate information, based on evidence and the realities of the lives of people with HIV goes someway to challenging the prejudice, ignorance and stigma that still surround HIV and those affected by it. I find my work useful, I hope you do too.

Michael Carter
Editor, HIV Weekly

Anti-HIV treatment

Potent anti-HIV treatment has brought a longer, healthier, life to millions of people around the world. But HIV drugs don’t work as well as they could in many people because the virus is resistant to some of the medicines available to treat it.

People with drug-resistant HIV used to have quite limited treatment options, but this has gradually changed because doctors have developed better skills and due to the availability of new drugs that have been developed specifically for people who have taken a lot of anti-HIV medicines in the past.

It is now thought that even patients with a lot of resistance to antiretroviral drugs should be able to get an undetectable viral load provided that they are treated with the right combination of drugs, and crucially, take these drugs properly.

A lot of research is still underway into the best way to treat patients who develop resistance. One recently published study has shown that people whose CD4 cell count declined at a slower rate before they started HIV therapy accumulated drug resistance more slowly than patients with greater CD4 cell count loss.  But the same study also showed that the longer people stayed on a combination of anti-HIV drugs that was failing to control viral load, the fewer anti-HIV drugs they had available for use in the future, with 1.25 drugs lost every six months a failing combination was used. For this reason it is important not to stay on a combination of anti-HIV drugs that isn’t suppressing your viral load to undetectable levels if you have other treatment options available to you.

A second study suggests that few people who become resistant to tenofovir (Viread) go on to develop resistance to drugs from the class of drugs that provide the backbone of most anti-HIV drug combinations, nucleoside reverse transcriptase inhibitor class (NRTI, or ‘nukes’ for short).

HIV that is resistant to a particular drug is said to have a ‘mutation’ and the key mutation that confers resistance to tenofovir is called K65R. Doctors should use resistance tests to looks for the presence of this and other resistance mutations in people who have just been diagnosed with HIV, are about to start anti-HIV treatment, or whose viral load becomes detectable again after a successful response to HIV treatment. 

In the study, ten people had the K65R resistance mutation when starting a potent combination of anti-HIV drugs that included tenofovir. After 18 months of this treatment the pattern of drug resistance did not change significantly in most patients, although the HIV of four patients did evolve and develop further drug-resistant mutations. Crucially, however, none of the ten patients developed a key mutation that makes HIV resistant to multiple NRTIs.

Prevention of mother-to-child transmission

The risk of mother-to-child transmission of HIV can be reduced to less than 2% provided that the mother takes appropriate HIV treatment during pregnancy and labour, that the baby is born using a caesarean or an actively managed delivery, that the baby takes the anti-HIV drug AZT (zidovudine) for the first six weeks of its life, and, that the mother does not breastfeed where safe alternatives exist (such as in the UK).

The use of anti-HIV drugs to prevent mother-to-child transmission of HIV is generally thought to be safe. However, HIV-positive women who are pregnant should not take efavirenz (Sustiva) because it has been linked with a rare birth defect. There is some evidence that taking a protease inhibitor during pregnancy may increase the risk of having a premature, or low birth-weight baby. It is important to note, however this is a controversial subject, and other studies have shown that this is not the case.

But a new piece of research conducted in a laboratory in rats and mice suggests that children who are exposed to AZT to prevent mother-to-child transmission can develop genetic mutations associated with an increased risk of lung cancer in the future.

The doctors behind the study emphasise, however, that they are not recommending that anti-HIV drugs should no longer be used to prevent mother-to-child transmission. Rather, they recommend that children exposed to AZT should have their health closely monitored.

Sexual health and HIV

Good sexual health is important for everybody, but is especially so for people with HIV. Some sexually transmitted infections can be more severe and harder to treat in people with HIV, particularly if they have a weak immune system, and the inflammation and sores that some infections cause can mean that a person with HIV is more likely to pass on HIV to their sexual partners if they have unprotected sex.

Herpes simplex virus-2 (HSV-2) is a sexually transmitted infection that causes painful sores on the genitals, anus, and sometimes, on the face, and has been associated in several studies from around the world with an increased risk of HIV transmission. Some researchers have also speculated whether HIV-positive people who are infected with HSV-2 have a worse prognosis, and that there is some evidence that treating HSV-2 may lower HIV viral load.

But now an American study involving 122 people with HIV has found that infection with HSV makes no difference to HIV viral load during the early stages of HIV infection (often called ‘acute’ or ‘primary’ infection). Researchers found there was no real difference in the viral load of the HSV-infected and HSV-negative patients.

They emphasise that their findings might be influenced by the type of people involved in the study – most were white men in good health who had enough to eat. They note that an earlier study in Uganda had found that HIV-positive people with HSV-2 had higher HIV viral load and wonder if this could be related to factors such as poor nutrition or the presence of other infections such as malaria and tuberculosis.

Travel

The Australian prime minister, John Howard, has suggested that the country may introduce a ban on HIV-positive immigrants.

Responding to reporting that there had been 70 HIV-positive immigrants into the state of Victoria over the last two years, the Australian prime minister said: “"I think we should have the most stringent possible conditions in relation to that nationwide, and I know the health minister is concerned about that and is examining ways of tightening things up," Mr Howard said.”

But Mr Howard’s figures didn’t stand up to closer scrutiny as 50 of the migrants were diagnosed in other Australian states, and of the remaining 20 who were diagnosed overseas, eleven were either Australian or New Zealand citizens and had an automatic right of entry to the country.

Australia currently tests all immigrants applying for permanent residence, but a positive result is not grounds for refusal of entry. Most individuals with HIV are rejected because they may pose a burden to the public health services, but individuals with guaranteed employment in Australia would not be affected.

New from NAM