Editorial

It’s back to normal with this edition of NAM HIV Weekly. There’s a good selection of news about HIV treatment, side-effects, and illness.

The news is divided into the following sections:

• Starting HIV treatment: study looking at the use of tipranavir (Aptivus) by people who have never taken HIV treatment before is stopped.
• Changing HIV treatment: people who are taking a triple NRTI combination should switch to treatment that includes an NNRTI or “boosted” protease inhibitor, even if they have an undetectable viral load, a study suggests.
• Options for people with treatment experience: atazanavir/ritonavir (Reyataz) has a more powerful anti-HIV effect than expected in people who’ve taken a lot of anti-HIV drugs. 
• Side-effects: a genetic test to see who is vulnerable to the abacavir (Ziagen) hypersensitivity reaction shows its worth in an Australian study; and taking ddI (Videx) for a long period has an association with liver side-effects in a small number of Spanish patients.
• HIV and illness: HIV-positive smokers seem more likely to get a new AIDS-defining illness and die, even when taking HIV treatment, than HIV-positive non-smokers; and a review article finds that there’s not enough evidence to recommend anal Pap smears for people with HIV.

Starting HIV treatment

It is currently recommended in the UK that people who are starting anti-HIV treatment for the first time should take a combination of anti-HIV drugs that includes either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a “boosted” protease inhibitor (so called because its potency is increased by the addition of a small dose of the protease inhibitor ritonavir [Norvir]).

The boosted protease inhibitors currently recommended for use in first-line HIV treatment in the UK are Kaletra (lopinavir/ritonavir), saquinavir/ritonavir (Invirase) or fosamprenavir/ritonavir (Telzir).

Tipranavir (Aptivus) is a boosted protease inhibitor that has been shown to work well in people who have taken a lot of anti-HIV drugs before and have resistance to them. It produces particularly good results when combined with T-20 (enfuvirtide, Fuzeon). However, tipranavir is not recommended for people new to anti-HIV treatment, and it doesn’t look like that this is going to change. A study looking at the use of the drug in people who’d never taken anti-HIV treatment before found that they had lower reductions in their viral load than people taking Kaletra. The study, conducted in several countries including the UK, has been halted.

However, tipranavir still remains an important option for people who have extensive prior experience of anti-HIV therapy.

Changing HIV treatment

The British HIV Association (BHIVA), the professional organisation of UK HIV doctors, recommends that people taking anti-HIV therapy should take a combination of three or more anti-HIV drugs, either two drugs from the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) with a non-nucleoside reverse transcriptase inhibitor (NNRTI) or two NRTIs plus a “boosted” protease inhibitor. These combinations have been shown to have a very powerful anti-HIV effect if taken properly, suppressing and keeping viral load at undetectable levels.

Combinations consisting of three nucleosides/nucleotides are not recommended. This is because this combination offers less durable suppression of viral load and is associated with an increased risk of HIV developing resistance to anti-HIV drugs.

Now a study conducted in Italy has now shown that people taking the triple NRTI combination of AZT, 3TC and abacavir (Trizivir) were 85% more likely to experience a rebound in their HIV viral load than people who took two NRTIs plus an NNRTI, even if they initially had good HIV suppression.

It had been thought that one of the potential advantages of triple NRTI treatment was a lower risk of increased blood fats – a long-term risk factor for illnesses such as heart disease. However, the Italian researchers found that there was no real difference in the levels of blood fats in the NRTI/NNRTI and triple NRTI treated patients.

The Italian doctors recommend that people taking triple NRTI treatment should switch to more powerful combinations including an NNRTI or a “boosted” protease inhibitor regardless of whether they currently have an undetectable viral load.

Options for people with treatment experience

Atazanavir (Reyataz) is a ritonavir “boosted” protease inhibitor. In the UK, it is only available for use by people who have taken anti-HIV drugs before, but in the US it can be used to treat people taking their first anti-HIV drugs combination.

One of atazanavir’s advantages is that it can be taken once daily. Like all anti-HIV drugs it causes side-effects, one of which can be a yellowing of the skin and whites of the eyes called jaundice. This side-effect isn’t dangerous, but some people find it distressing.

A Spanish study involving people who had taken a lot of anti-HIV drugs before and had drug resistant HIV showed that combinations that contained atazanavir/ritonavir could be very powerful. Almost half of the 56 people in the study had an undetectable viral load a year entering the study.

Atazanavir/ritonavir was taken in combination with once-daily tenofovir (Viread) and ddI (Videx). The combination of tenofovir and ddI is not generally recommended as it can result in a fall in CD4 cell count.

Side-effects

HIV and illness

Thanks to potent anti-HIV treatment there has been a dramatic fall in the amount of illness and death caused by HIV in countries like the UK. When people do now become ill or die because of HIV it is often because their HIV was diagnosed so late that anti-HIV treatment didn’t have a chance to work. Many HIV doctors now believe that as long as a person with HIV has their HIV diagnosed before the immune system is too damaged, take their HIV treatment properly, can tolerate their treatment and isn’t infected with another disease like hepatitis C, then they could have a near-normal normal life span, with a prognosis that is so good that HIV is something they die with rather than because of.

However, despite all this optimism, not everybody taking anti-HIV therapy does well, and some rare diseases and cancers occur more frequently in people with HIV. A number of recently published studies cast some more light on the reasons behind this.

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