The news highlights of this week were:

• Have your say: The Department of Health wants the views of people with HIV on its plans to tackle HIV-related stigma and discrimination.
• Treatment breaks: Another treatment interruption study is halted, but the doctors who coordinated it still believe that structured treatment breaks will have a place in long-term HIV treatment.
• Lipodystrophy: Our understanding of why certain anti-HIV drugs can cause body fat changes has been advanced by a small study showing that people with fat loss have a neurotransmitter in their fat tissue.
• HIV and women: Middle-aged HIV-positive women have an increased risk of bone weakness, a study has found, but treatment with anti-HIV drugs doesn’t seem to increase the risk of it occurring.
• Longer-term HIV treatment: Atazanavir/ritonavir is as potent as Kaletra over two years but has a better side-effects profile.

This is your last chance to contribute your experiences of HIV for inclusion in the next edition of Living with HIV. Email michael@nam.org.uk by Wednesday 29^th March.

Treatment breaks

Another study looking at the value and safety of structured treatment interruptions has been stopped early.

The treatment interruption component of the DART study in Africa was halted early after doctors noticed that people who interrupted their treatment were significantly more likely to develop HIV-related illnesses. These illnesses were treatable, the most common being thrush (candidiasis) in the throat, but the study’s doctors concluded that intermittent treatment could not be recommended for people who started HIV treatment with a CD4 cell count below 200 or who had a history of AIDS-defining illnesses before starting HIV therapy.

A total of 799 people were included in the study. They were randomised to either take HIV treatment all the time or to take HIV treatment and treatment breaks in twelve-week cycles.

This is the second major treatment interruption study to be halted early this year. In January, the SMART study was terminated early after it was found that people who took breaks from their HIV treatment guided by increases in their CD4 cell count were more likely to become ill.

Nevertheless, the doctors involved in the DART study do not believe that the termination of their investigation into treatment interruptions means the end of studies looking at treatment breaks. They commented: “the need to interrupt [HIV] therapy for multiple reasons, e.g. drug toxicity, is likely to remain an integral part of life-long treatment for HIV disease. Finding out how and when therapy can be interrupted safely and which patients may benefit from such strategies are still important questions and should be pursued in future trials.”

Lipodystrophy

It is now well known that changes in body fat shape can be a major and distressing side-effect of anti-HIV treatment. Two drugs from the nucleoside analogue (NRTI) class, d4T (stavudine, Zerit) and, to a less extent AZT (zidovudine, Retrovir) have been particularly associated with fat loss (also known as lipoatrophy), and it is now recommended that people do not take these drugs if they have other options available to them.

There’s a lot of research underway into the exact reasons why anti-HIV drugs can cause fat loss. It is well known that both d4T and AZT can damage the mitochondria (which carry energy in cells).

Now researchers have found that people who experienced fat loss whilst taking HIV treatment had high levels of a neurotransmitter – a brain chemical that allows nerve cells to communicate with the body – called norandrenaline in their fat tissue. 

More research is now needed to show if these changes are linked to the effects of anti-HIV drugs in the brain.

Women and HIV

In richer countries HIV has usually been seen as a disease that mainly affected young adults. This is gradually changing. Thanks to the success of potent anti-HIV treatment many people with HIV are now living much longer lives. But this can bring its own health problems and there is increasing interest in how diseases and illness associated with middle- and older-age affect people with HIV.

More HIV-positive women are living into and beyond their menopause (the ending of the ability to have children). A weakening of the bones can be a consequence of the menopause, and there has been some concern that anti-HIV drugs can also affect the strength and density of bones.

Now, an American study involving just under 500 middle-aged women (average age 44) has found that HIV-positive women are more likely to have low bone density (osteopenia) than HIV-negative women. Other risk factors for bone weakness included low body weight, a past history of bone fractures, use of the hormone oestrogen, and use of opium-based drugs.

However, no link was found between the use of anti-HIV drugs and low bone density.

HIV-positive women entering the menopause should have health checks to see if they have osteopenia, the study’s doctors conclude and calcium and vitamin D treatment should be considered.

Longer term HIV treatment

Clinical trials are always conducted on new anti-HIV drugs before they are approved for use. These studies need to show that the use of the drug has a benefit and that it is safe to use. They normally involve thousands of HIV-positive people in a number of different countries and last for 48 weeks.

Drug companies often keep on looking at the effectiveness and safety of drugs for a period of time after this.

Researchers from the drugs company Bristol Myers Squibb (BMS) have published 96-week results from their study comparing the effectiveness and safety of their protease inhibitor atazanavir (Reyataz) boosted by low dose ritonavir against Kaletra (lopinavir/ritonavir). The study involved people who had taken two anti-HIV treatment combinations before.

The 96-week results showed that atazanavir/ritonavir-based and Kaletra -based combinations were equally effective at getting HIV viral load down to undetectable levels and keeping it there. There was no difference in the average CD4 cell count increase seen in people taking the two drugs.

Nor was there any difference in the percentage of people who experienced a severe side-effect. However, the researchers found that people taking Kaletra were significantly more likely to develop diarrhoea than those taking atazanavir/ritonavir.

What’s more, they found that although Kaletra increased the amount of cholesterol and triglycerides in people’s blood, use of atazanavir/ritonavir lead to a fall in both cholesterol and triglycerides.

People taking Kaletra were much more likely than those taking atazanavir/ritonavir to need to take treatment to control their diarrhoea or to take drugs to control the level of fats in their blood.

Atazanavir can cause a condition called hyperbilirubinaemia involving a yellowing of the skin and eyes. It is not dangerous but can be distressing. Although approximately 15% of people taking atazanavir/ritonavir developed hyperbilirubinaemia, none stopped treatment because of this.