• HIV disease progression: a high viral load and being very ill soon after infection with HIV are connected with poorer survival, a study has found; and HIV-positive people with mental health problems live just as long as those without, but take more anti-HIV drugs and spend more time in hospital.
• HIV and illness: people with a high viral load taking anti-HIV treatment are more likely to be admitted to hospital with bacterial pneumonia; and two new blood tests provide an accurate way of detecting latent infection with tuberculosis.
• HIV and hepatitis C: HIV-positive people with the easier-to-treat strains of hepatitis C may only need 24 weeks of treatment with full-dose anti-hepatitis C treatment to get good results, with blood tests after only four weeks predicting who is going to respond to treatment.
• Mother-to-child transmission of HIV: women who take a protease inhibitor during pregnancy appear to have an increased risk of having a premature baby, according to an American study. But some doctors think that there's a need for more studies before this is know for certain.
• Anti-HIV treatment - side-effects: a small study has found that efavirenz (Sustiva) causes only modest sleep disturbances; and people taking anti-HIV treatment who have a high viral load or who inject drugs are more likely to develop an early symptom of cardiovascular disease.
• Superinfection: the first confirmed case of superinfection in the UK is reported, involving a young gay man who was reinfected with a drug-resistant strain of HIV soon after first contracting the virus.

HIV disease progression

HIV and illness

HIV and hepatitis C

Liver disease caused by hepatitis B or hepatitis C virus is now one of the leading causes of illness and death amongst people with HIV in countries like the UK where anti-HIV treatment is available. Although treatment for hepatitis C is available, it is less effective in people with HIV than it is in people who only have hepatitis C.

Concerns about side-effects sometimes mean that people with HIV are treated with lower doses of hepatitis C treatment than are used in people who only have hepatitis C. A study conducted by Irish doctors has found that using the full dose of the anti-hepatitis C drugs pegylated interferon and ribavirin can “cure” hepatitis C after only 24 weeks of treatment in HIV/hepatitis C-infected people, provided that they have the easier-to-treat strains of hepatitis C, genotypes 2 and 3.

Unfortunately, a disappointing response to treatment was seen in people who had the harder-to-treat genotypes 1 and 4.

The doctors used the drug erythropoietin (EPO) and blood transfusions in some patients to help make treatment more tolerable. Nevertheless, 90% of people reported ‘flu-like symptoms, 22% reported depression and 40% had blood disorders.

There are some points that need highlighting about this study. First of all, it was small, involving only 45 people. It also needs to be seen within the context of doctors trying to develop treatment strategies to improve the response to hepatitis C treatment in people with HIV. The standard duration of treatment for people with HIV and hepatitis C is 48 weeks, but some doctors have suggested that people with genotypes 1 or 4 may need up to a year and a half of treatment to stand any real chance of having a successful response. There has also been some interest in increasing the dose of ribavirin.

Another important finding of the Irish study was that you could predict four weeks into treatment who was going to respond to treatment – this might spare people who ultimately fail on hepatitis C treatment months of unpleasant side-effects.

Mother-to-child transmission of HIV

HIV can be passed on from a mother to her baby in the womb, during delivery, or by breastfeeding. There is an 8% risk of this happening, but this risk can be cut to less than 1% by the use of anti-HIV drugs, using a caesarean delivery if a mother has a detectable viral load, and by not breastfeeding.

Not all anti-HIV drugs can be used during pregnancy. The non-nucloeside reverse transcriptase inhibitor (NNRTI), efavirenz (Sustiva) should not be taken by pregnant women, or women who are thinking of becoming pregnant, because it has been associated with severe birth defects. Some, but not all, studies have found that the use of a protease inhibitor during pregnancy increased the risks of having a low weight or premature baby.

Now, an American study has been published which also shows that women who took a protease inhibitor during pregnancy were more likely to have a premature baby than those who took AZT monotherapy (an option for women who are in good health and have a low viral load), or an NNRTI .

But an editorial accompanying the study highlights how doctors looking at the risks of premature birth have often come up with different results. This could be because they aren’t using the correct trial design to identify the true risk. They suggest that the real risk of premature delivery can only be shown by the use of a randomised, controlled trial. The studies so far have just looked at, or observed, outcomes and their ability to provide definite answers is therefore limited. To find out more about the design of clinical trials click here.

Anti-HIV treatment – side-effects

Anti-HIV treatment means a longer and healthier life, in fact many HIV doctors are now so optimistic about the effectiveness of HIV treatment that they think that provided a person with HIV starts treatment with HIV soon enough, takes their treatment properly, and can tolerate it, they will live just as long as an HIV-negative person.

But all the currently available anti-HIV drugs have unwanted side-effects. Many of these are short-term and fade or go away completely after the first few weeks of treatment with the drug, but others become a permanent feature of life with the drug. One of the main reasons why people have to change their HIV treatment is side-effects, and some side-effects are not only unpleasant, but can increase the risk of longer-term health problems occurring.

Superinfection

Questions about superinfection are frequently asked of doctors and others working in health promotion, but it’s an area where speculation is rife. Few clinics have been able to carry out careful research on the subject, but one centre that did, the Royal Free Hospital in London, recently identified the UK’s first confirmed case of superinfection with drug-resistant HIV.

The clinic identified a case of superinfection that appears to have taken place approximately five months after initial seroconversion. This finding in itself is unsurprising, and should reinforce the need to counsel recent seroconverters about the increased risk of superinfection that seems to exist during the early months of HIV infection, before the immune response strengthens and/or diversifies.

However the case also reinforces the observation that when people become superinfected with drug-resistant viruses, it can change the balance between the immune system and the virus that was achieved after primary infection, leading to faster disease progression.

The case report can’t tell us anything about the frequency of superinfection, but it’s quite possible that such cases of rapid progression during the early months of infection will be observed more frequently as HIV antibody testing becomes more frequent and routine in the United Kingdom and the United States.

For more on superinfection, click here.