Treatment changes in the UK

Side-effects are the main reason that people taking their first or second combination of anti-HIV drugs change treatment, UK HIV workers were told at the recent Autumn conference of the British HIV Association (BHIVA), the professional organisation of doctors involved in HIV treatment and care.

Just over half of people who changed treatment did so because of side-effects, with problems associated with lipodystrophy, including fat loss, high blood pressure and high levels of the blood fat, triglycerides being the main reason for a treatment change.

Other common side-effects which caused treatment changes included those affecting the central nervous system (such as depression and sleeping problems), which were nearly always caused by efavirenz (Sustiva) and peripheral neuropathy (painful nerve damage in the hands and feet), which can be caused by some drugs in the nucleoside analogue (NRTI) class.

After side-effects, viral load “failure” was the main reason for treatment being changed. “Failure” was defined as either viral load not falling to undetectable (below 50 copies/ml) despite treatment, or “rebounding” to detectable levels in two or more viral load tests after being detectable.

Current UK treatment guidelines say that everybody who needs to change treatment due to virological failure should have a resistance test to see which drugs will work best in their next combination. However, the BHIVA Autumn conference was told that only happened for 72% of cases. Doctors were told that they should “ensure appropriate use of resistance testing.”

Treatment breaks

People who had a lowest ever CD4 cell count below 250 cells/mm³ are much more likely to need to restart treatment within 15 months of commencing a structured treatment break, no matter what their CD4 cell count was when they started a break from treatment, Canadian researchers have found.

“Treatment interruption is a viable option for HIV-positive adults without an AIDS-defining illness and with nadir CD4 cell counts above 250 cells/mm³”, the researchers conclude.

A major clinical trial called the SMART study is currently looking at the safety and effectiveness of treatment breaks guided by CD4 cell count as a long-term HIV treatment strategy. It is recruiting at HIV treatment centres across the UK.

Use of T-20

New US HIV treatment guidelines recommend that people who have extensive experience of HIV treatment should still receive treatment with the aim of suppressing viral load to undetectable levels.

The guidelines suggest that people who have taken drugs from all the main classes of anti-HIV drugs and still have a detectable viral load should be treated with a ritonavir -“boosted” protease inhibitor such as tipranavir in combination with the fusion inhibitor T-20 (enfuvirtide, Fuzeon ) with the aim of suppressing viral load.

CCR5 trial

Clinical trials into the safety and effectiveness of Pfizer’s CCR5 inhibitor, maraviroc can continue without any changes in their design or structure, an independent safety and monitoring committee has concluded.

During the summer, the drug company GlaxoSmithKline announced that it was stopping the study into its CCR5 inhibitor aplaviroc involving people who had never taken anti-HIV drugs before after unexpectedly high levels of liver side-effects were reported.

The Pfizer safety view board found no evidence of increased levels of liver problems in studies into maraviroc involving either treatment-experienced, or treatment-naïve people.

Hepatitis C coinfection

Men who are coinfected with HIV and hepatitis C are significantly more likely to have detectable levels of hepatitis C in their semen, than men who are only infected with hepatitis C, a study has found.

French researchers found that hepatitis C was found in the semen of 38% of HIV-positive men, but in the semen of only 18% of men HIV-negative men.

The investigators believe that this finding could partly explain the recent outbreaks of sexual transmission of hepatitis C involving gay men.