Editorial

On a personal note…

From December last year, it’s been possible for same sex couples to form Civil Partnerships in the UK. And by the time you read this, provided that there aren’t any unforeseen circumstances, that’s exactly what my partner of 14 years and I will have done. So I thought I’d use this edition of HIV Weekly to provide some information (extracted from the NAM book, Living with HIV ) on the rights and responsibilities which UK Civil Partnerships provide that HIV-positive people might find interesting.

There’s also a selection of the latest HIV research reported on aidsmap.com in the last week or so. One piece that stood out was the finding of a study conducted in Singapore, showing that people who were malnourished at the time they started HIV treatment had a much greater risk of death than people who had good nutritional status. It underlined to me the importance of good nutrition, and generally looking after your health, even if you are taking HIV treatment. A good place to learn more about nutrition is NAM’s information booklet on the subject and the next edition of Living with HIV has lots of useful information on day-to-day health issues and subjects such as exercise.

• New drug approved in US: The protease inhibitor darunavir (TMC114) has been approved in the US for use by people who’ve taken a lot of HIV drugs before.
• Nutrition: People who are malnourished when they start anti-HIV treatment have poorer survival.
• Symptoms and illnesses: A study suggests that grey nails in HIV-positive African people can be a sign that they need to start HIV treatment; and researchers have found that having the AIDS-defining cancer Kaposi’s sarcoma on the lungs is bad news.
• HIV and hepatitis: The drugs ddI (Videx) and d4T (Zerit) are associated with a fatty liver in people with HIV and hepatitis C.

New drug approved

The Food and Drug Administration in the US last week approved the protease inhibitor darunavir (formerly called TMC114) for use by people who have taken a lot of anti-HIV drugs before.

The dose of darunavir is 600mg twice a day, boosted by 100mg of ritonavir, with food. Darunavir was approved after studies showed that people who had a lot of resistance to other protease inhibitors experienced a better reduction in their viral load when taking darunavir than people with resistance who were taking some other ritonavir-boosted protease inhibitors.

People in these trials took darunavir with other anti-HIV drugs that were selected after resistance tests (the “optimised background”). Particularly good results were seen in people who took darunavir and their optimised background along with the anti-HIV drug, T-20 (enfuvirtide, Fuzeon).

The manufacturer of darunavir, Tibotec, has announced that the drug will cost less than the protease inhibitor tipranavir (Aptivus), which is an alternative protease inhibitor for people with very limited treatment options. This move has been welcomed by treatment activists in the US.

Approval for darunavir in Europe is expected later this year.

Nutrition

Potent anti-HIV treatment can mean a longer, healthier life for people with HIV. But even if you are taking successful HIV therapy it’s important that you look after your general health.

Diet and nutrition are of fundamental importance to health. Much of the attention in recent years has been focused on the importance of a healthy, low fat diet, rich in fruit and vegetables if you experience increases in the levels of fat in your blood caused by anti-HIV drugs. 

Wasting caused by HIV itself, and the infections to which people with untreated HIV are vulnerable, was a significant cause of death before effective anti-HIV drugs became available. Wasting remains a serious issue today. Studies have also shown that even amongst people taking successful anti-HIV treatment, the unintentional loss of just 3% of body weight significantly increases the chance of dying.

Now a study conducted in Singapore has found that people who are malnourished when they start potent anti-HIV treatment are six times more likely to die than HIV-positive people with good nutritional status. They determined who was malnourished by looking at body weight and height and working out people’s body mass index (BMI). The higher risk of death was associated with a BMI below 17.5kg/m². You can work out your BMI by clicking on the BBC’s website by clicking here. The researchers then looked at how well people did after starting anti-HIV treatment. People who were malnourished when they started powerful anti-HIV treatment were six times more likely to die than people who were well nourished.

Interestingly, similar increases in CD4 cell count were seen in patients with poor nutrition and good nutrition leading the study’s authors to speculate that factors such as poorer absorption or drugs, inability to cope with treatment side-effects, or just general weakness and poorer physical function lead to the increased risk of death seen in people with malnutrition.

Speak to a dietitian if you are concerned about your diet or weight.

Symptoms and illnesses

We’re used to doctors making decisions about when to start HIV treatment by looking at the results of the key blood tests CD4 cell counts and viral load tests. In the UK it is recommended that everybody whose CD4 cell count is 250 or below should start anti-HIV treatment, as a CD4 cell count of this level indicates a real risk of becoming ill with a potentially fatal infection. It’s also recommended that people who are ill because they have HIV should start HIV treatment.

Certain symptoms can indicate that HIV is damaging a person’s immune system - for example, infections like oral thrush and skins complaints like molluscum.

Now researchers working in Malawi have found that grey nails are an accurate predictor that a person has HIV, a CD4 cell count of around 250, and are in need of HIV treatment.  Looking for grey nails won’t replace the usual method of monitoring HIV in the UK – but it’s a useful additional tool in developing countries.

Another recently published study suggests that late diagnosis was a major reason why some people developed the AIDS-defining cancer Kaposi’s sarcoma (KS) on their lungs. Researchers in London found that although pulmonary KS has become rarer and survival has improved since effective anti-HIV treatment became available, the average period of survival for people diagnosed with it was only 19 months. The researchers found that 80% of people with pulmonary KS had taken less than three months of anti-HIV treatment and that only a handful had an undetectable viral load, suggesting to them that these patients had only had their HIV diagnosed when they already had very weak immune systems and were unwell because of HIV. The researchers also noted that Africans were the group most likely to be diagnosed with pulmonary KS – once again this was because of late diagnosis.

In addition, the researchers found that people with pulmonary KS had much poorer survival than people who had KS on their skin – only 50% of people with KS on their lungs were alive five years after it was diagnosed compared to over 80% of people who had KS in other areas. It is well known that KS on the internal organs involves a much worse prognosis than KS on the skin.

HIV and hepatitis

Hepatitis B virus and hepatitis C virus can be transmitted in similar ways to HIV and as a result many HIV-positive people are also infected with one or both of these viruses. This is often called coinfection, and liver disease caused by hepatitis B or hepatitis C has emerged as one of the main causes of illness and death in coinfected people since potent anti-HIV treatment became available.

People who have hepatitis C have an increased risk of developing a fatty liver (hepatic steatosis). A fatty liver has been seen in as many as 40% of people with HIV and hepatitis C.

Now American researchers have found that the prevalence of fatty liver amongst people with HIV and hepatitis C might be as high as 66%.  Although they found that being overweight was a risk factor for developing a fatty liver, the biggest risk factors were the use of the anti-HIV drugs ddI (Videx) and d4T (Zerit). It is known that these drugs can damage cells that carry energy, or mitochondrial toxicity, causing side-effects such as peripheral neuropathy or facial wasting and the researchers speculate that mitochondrial toxicity caused by these drugs might also lead to the development of a fatty liver.

The American researchers recommend that people with HIV and hepatitis C avoid ddI and d4T.

Civil Partnerships

Since December 2005 it’s been possible for same sex couples in the UK to register Civil Partnerships – basically become married in all but name.

Civil Partnerships provide exactly the same next-of-kin rights and responsibilities as heterosexual marriage.

The latest edition of the NAM book Living with HIV, which will be published in the next few weeks has been revised to take account of these changes.

In the book you can read how Civil Partnerships can effect the finances of couples; the property rights and rights of succession they provide; and the rights they provide for visiting a partner in hospital.

Living with HIV is free to HIV-positive people. To order a copy of the new edition email info@nam.org.uk.