Integrase inhibitors and diabetes

Different anti-HIV medications are grouped into different drug ‘classes’. In recent years, one of the most widely used has become the integrase inhibitor class, because they are extremely effective and are thought to have relatively few side effects.

Four integrase inhibitors are approved for use in people living with HIV: raltegravir (Isentress), dolutegravir (Tivicay, also in Triumeq, Juluca and Dovato), elvitegravir (in Stribild or Odefsey) and bictegravir (in Biktarvy).

However, scientists have now reported the possibility of diabetes occurring more frequently in people taking these drugs. This result will need to be confirmed in other studies.

The American researchers looked at over 21,000 people starting HIV treatment: half started treatment that included a drug from the NNRTI or ‘non-nuke’ drug class; a third started with a protease inhibitor; and the rest had an integrase inhibitor.

Overall, 3% of people developed diabetes. Compared to people taking the first type of drug, people taking protease inhibitors had a 25% increased risk of diabetes (not an unexpected finding). Also, people taking integrase inhibitors had a 22% increased risk (the first time this has been reported).

It seems that there was a particular problem with one of the integrase inhibitors, raltegravir.

An analysis earlier in the year of the same group of patients found that people starting integrase inhibitors put on more weight than people on other types of anti-HIV drugs. It’s possible that the two problems are linked.

For more information, read NAM's page 'Type 2 diabetes and HIV'.

No-deal Brexit

There is little clarity about how UK citizens living elsewhere in the European Union will continue to get HIV treatment in the event of a no-deal Brexit, legal professors say.

They looked in particular at the situation in Spain. As a third of the UK citizens living in the European Union (EU) are in Spain, this is a particularly relevant example.

If the UK remains part of the EU, British citizens living in other European countries will continue to have access to health care, as guaranteed by EU law. Similarly, if the UK government resurrected Theresa May’s withdrawal agreement, this would safeguard healthcare rights for UK citizens resident in other EU countries.

But if the UK leaves the EU without a deal, it’s unclear how UK citizens living with HIV in Spain will get health care. Eventually, the UK and Spanish governments might come to an agreement about health care for their citizens living overseas, but for the moment there is nothing in place.

This leaves UK citizens in Spain with three options:

• Pay directly for their anti-HIV medication – around €8000 a year.
• Get private medical insurance – but this will be expensive for people with a pre-existing medical condition.
• Buy an individual subscription to the Spanish health system – but HIV treatment will not be covered.

UK citizens living in Spain will also need to get a residence visa.

Treatment for people with lots of resistance

The most recently approved anti-HIV drug is called ibalizumab (Trogarzo) and is specifically for people who have very few treatment options left because their virus is resistant to many existing drugs.

It works in a different way to existing treatments and is taken differently – as an intravenous infusion every two weeks. Although it doesn’t need to be taken daily, it should be taken in combination with other anti-HIV medications (daily pills) that are still effective.

American researchers have reported on a group of 38 people using this drug. They were resistant to antiretrovirals from at least three drug classes, but their virus was still sensitive to at least one antiretroviral medication. Half had a CD4 count below 50, indicating advanced suppression of the immune system.

Over half had a substantial decrease in their viral load (a 1 log₁₀ drop) within a week. Although only 24 of the 38 were still on the treatment one year later, half of this group had an undetectable viral load.

Ibalizumab was generally safe and well tolerated – the most common side effects were diarrhoea, headache, nausea, cough, skin rash and fatigue, in most cases mild or moderate.

Children and young people

There are high levels of engagement in care by children and young people living with HIV in the UK and Ireland, researchers report.

In 2016, 98% had attended their HIV clinic at least once that year, 92% of those in care were taking HIV treatment and 86% of those taking treatment had an undetectable viral load.

The uptake of treatment has improved since a previous survey in 2010, but the proportion with an undetectable viral load has not. Younger children were more likely to be doing well on treatment than older adolescents.