• HIV treatment – when to start treatment
• HIV treatment – darunavir monotherapy
• Hepatitis C – infections continuing to increase amongst HIV-positive gay men
• TB – still a major health issue for people with HIV
• HIV treatment – when to start treatment

There’s a lot of debate about the best time to start taking HIV treatment.

In the UK, it’s currently recommended that everybody who is ill because of HIV should take anti-HIV drugs. Treatment is also recommended for people who have a CD4 cell count of around 350.

But some doctors think there would be additional benefits if treatment was started at higher CD4 cell counts.

Now an international study involving over 1200 people has shown that there are advantages to starting treatment soon after infection. The research also allayed some concerns about the possible risks of early treatment.

The researchers monitored their patients’ viral load. They wanted to see how many people experienced ‘treatment failure’ (defined as two viral load results over 400 copies/ml while on treatment) and how many patients developed drug-resistant HIV.

After eight years, 18% of patients had experienced treatment failure, and 6% had drug-resistant virus. This rate of failure was lower than the rate observed in a comparison group of people who started treatment according to current guidelines.

Older patients were less likely to develop resistance – possibly because they were more likely to take their treatment properly.

Starting treatment with a higher CD4 cell count was also associated with a reduced risk of treatment failure.

Each increase of 100 in CD4 cell count reduced the risk of treatment failure by 8% and the risk of resistance by 26%.

The researchers concluded that starting treatment early did not lead to high levels of resistance.

HIV treatment – darunavir monotherapy

It is recommended that HIV should be treated with a combination of at least three different anti-HIV drugs.

This means that treatment has a very powerful effect against the virus, and that there’s a low risk of drug resistance developing.

However, newer ritonavir-boosted protease inhibitors are very effective against HIV, and studies are underway to see if these drugs can be used as HIV treatment by themselves (known as ‘monotherapy’).

In the summer, results from one study showed that, after two years, 75% of patients taking ritonavir-boosted darunavir (Prezista) monotherapy had an undetectable viral load, compared to 81% of those taking traditional three-drug treatment.

The researchers have looked at their results again and found that darunavir monotherapy was just as effective as triple-drug therapy at suppressing viral load to extremely low levels.

They used an ultra-sensitive test, and found that after two years 17% of people taking monotherapy had a viral load between 5 and 50 copies/ml compared to 15% of patients who were taking triple therapy.

Hepatitis C – infections continuing to increase amongst HIV-positive gay men

HIV-positive gay men are still contracting hepatitis C virus, research from Hamburg shows.

There have been outbreaks of sexually transmitted hepatitis C among HIV-positive gay men in a number of European cities.

Liver disease caused by hepatitis C is a major cause of illness and death in HIV-positive patients who are co-infected with the virus

Unprotected sex, fisting, group sex, and drug use have been identified as risk factors for sexual transmission of the virus in gay men with HIV.

Researchers in Hamburg monitored approximately 5000 gay men between 2002 and 2010 to see how many became infected with hepatitis C.

A total of 99 were diagnosed with hepatitis C, and 88 of these were newly infected with the virus. Nearly all these men were HIV-positive.

In the first half of 2010, nine men were newly diagnosed with hepatitis C.

The researchers also found that a quarter of men who cleared the virus with treatment were re-infected with hepatitis C.

Issue 197 of our regular publication, HIV treatment update, included the feature Staying free of hepatitis C, which is now available online. For more information on HIV and hepatitis C co-infection, download our booklet HIV & hepatitis.

TB – still a major health issue for people with HIV

Tuberculosis (TB) is the single biggest cause of serious illness and death in people with HIV worldwide.

Even in resource-rich countries like the UK, TB is one of the most common AIDS-defining illnesses.

New research has shown that every day 4000 people with HIV die because of TB worldwide.

Most of these deaths are in sub-Saharan Africa.

Only about a third of patients with HIV/TB are receiving HIV treatment, and few people are receiving TB preventive treatment.

For more information on TB, visit our Tuberculosis & HIV webpages or download our patient information booklet.

Our booklets are also available free in clinics and organisations in the UK – if you work in a clinic or community organisation and would like to find out more about our ‘free booklet scheme’, contact us on 020 7840 0050 or info@nam.org.uk.

New from NAM

Social & legal issues for people with HIV is now available to buy from NAM.

Covering a range of topics including discrimination in employment, access to health care for migrants, the Equality Act 2010 and transmission of HIV as a criminal offence, this new resource is a practical guide to the issues, summarising social policy and legislation in the UK.

Social & legal issues for people with HIV is priced at £34.95 and an online version is also available on our website.

Visit our website to place an order, or contact us on 020 7840 0050 or by emailing info@nam.org.uk.

Calling all runners!

NAM has one place in the 2011 Virgin London Marathon. Should it have your name on it?

Visit our website for more information.

The 50 Plus Project

Recent research into the social impact of ageing with HIV in the UK.

This feature first appeared in our regular publication HIV treatment update and is now available on our website.

Facebook

Join our Facebook network – and ask your friends to join us too!

For more details, please contact NAM

tel: +44 (0)20 7840 0050
fax: +44 (0)20 7735 5351
email: info@nam.org.uk
web: www.aidsmap.com

• HIV treatment as prevention
• Side-effects of HIV treatment – bone loss
• Side-effects of HIV treatment – treatment for facial wasting
• HIV treatment as prevention

There’s a lot of debate about the infectiousness of people taking HIV treatment who have an undetectable viral load.

HIV treatment lowers viral load in the blood and other body fluids, including genital fluids.

In January 2008 some senior HIV doctors in Switzerland issued what has come to be known as the Swiss statement.

This said that in certain specific circumstances people taking effective HIV treatment should not be considered sexually infectious.

For this to be the case, the person must:

• Have had an undetectable viral load for at least six months.
• Take their treatment properly.
• Be free of other sexually transmitted infections.

The Swiss doctors based their statement on studies conducted in Africa which showed that there were no HIV transmissions in heterosexual couples when the HIV-positive partner was taking treatment and had an undetectable or low viral load.

There is a consensus that taking HIV treatment and having an undetectable viral load does reduce the risk of passing on the infection to others. However, most researchers think that there’s still a small risk. In addition, much of the available research has focused on vaginal sex in heterosexual couples and may not reflect the transmission risk from anal sex.

Now Swiss investigators have found that people with HIV are more likely to report unprotected sex with a stable HIV-negative partner if they are taking antiretroviral treatment and have an undetectable viral load.

After the publication of the Swiss statement, there was a big increase in the number of HIV-positive people who reported using their viral load to guide decisions about condom use with their main HIV-negative partner.

However, the researchers note that this increase in unprotected sex was not accompanied by an increase in the number of people being infected with HIV.

Using illicit drugs and heavy alcohol use were also associated with unprotected sex.

But some doctors are concerned that people are using viral load to guide decisions about condom use.

An editorial accompanied the latest Swiss research. The author said there are still a lot of unanswered questions about the impact of treatment on infectiousness.

The Clinical Infectious Diseases journal article is available here and the editorial is available here.

Side-effects of HIV treatment – bone loss

Thanks to HIV treatment, many people with the virus can expect to live a long and healthy life.

But like all medicines, those used to treat HIV can cause side-effects.

There’s currently a lot of interest in the impact of treatment on the health of bones.

HIV itself can cause a loss of bone density – this can increase the risk of fractures. Some research has also shown that taking some anti-HIV drugs can reduce bone density.

Now a Spanish study has shown that 48% of HIV-positive patients have thinning bones, and in 23% this is serious enough to involve a risk of fractures.

Their research involved 671 patients. Bone density was assessed at least once using a type of body scan.

In addition, 391 patients had at least one other scan. The results of these showed that bone density worsened in 28% of patients.

Traditional factors for bone loss include older age and low body weight. The researchers found that these were associated with bone loss in their patients.

But they also found that current use of protease inhibitors, as well as length of treatment with a protease inhibitor or tenofovir (Viread, also in the combination pills Truvada and Atripla) were associated with reduced bone density.

The researchers believe that people taking HIV treatment should have their bone density monitored regularly.

This is because bone density can be improved with a good diet, by stopping smoking, and by certain types of exercise.

For more information on HIV-related bone loss, you can read our recent feature article Skeleton key on our website.

Side-effects of HIV treatment – treatment for facial wasting

The older anti-HIV drugs d4T (stavudine, Zerit) and AZT (zidovudine, Retrovir, also in the combination pills Combivir and Trizivir) can cause a side-effect known as lipoatrophy.

This involves loss of fat from the legs, buttocks and face.

These drugs are no longer recommended for routine, long-term use in high-income countries, and switching to other HIV drugs has been associated with very slow recovery of fat in the limbs.

But often the only treatment for facial fat loss is cosmetic surgery.

Doctors have reviewed studies looking at this treatment.

They found that patients’ suitability for surgery was assessed either according to the severity of fat loss, or because of its impact on their emotional and mental health.

Fat transfer was the researchers’ preferred treatment option for severe fat loss. For moderate or mild fat loss, they recommended the use of a biodegradable filler such as polylactic acid.

They found that complications did occur, they were quite rare and that side-effects were mild and went away with time.

For more information on side-effects, visit our website. Older anti-HIV drugs are more common in resource-limited settings. Visit our website for a clinical review of body-fat changes in people with HIV, written for healthcare professionals in resource-limited settings.
Calling all runners!

NAM has one place in the 2011 Virgin London Marathon. Should it have your name on it?

Visit our website for more information.

Seeking professionals’ views on new NICE testing guidance

The National Institute for Health and Clinical Excellence (NICE) is developing guidance on increasing HIV testing among men who have sex with men (MSM). It is intended for commissioners, NHS practitioners, local authorities and the wider public, private, voluntary and community sectors in England.

NatCen (National Centre for Social Research), Sigma Research and NAM are testing this guidance with practitioners in England.

If you work with or influence the lives of MSM, in health, social care, policy or advocacy, we need to hear your views. Please complete our online survey.

You can find out more about the survey, and complete it online, on the Sigma Research website here. We really value your input.

The survey closes at 5pm on Wednesday 10th November.

Staying free of hepatitis C

This feature first appeared in our regular publication HIV treatment update and is now available on our website.

HIV & the criminal law

HIV & the criminal law is now available to buy. Launched as a web resource during the International AIDS Conference in Vienna, the print edition is now in stock.

It explores the full range of issues relating to the criminalisation of HIV exposure and transmission around the world, with information on current laws and practice internationally.

Produced in a handy A5 size, HIV & the criminal law is priced at £34.95, but can currently be bought at a special introductory price of £29.95.

Contact us for more details, or to place an order, on 020 7840 0050 or by emailing info@nam.org.uk.

Facebook

Join our Facebook network – and ask your friends to join us too!

For more details, please contact NAM

tel: +44 (0)20 7840 0050
fax: +44 (0)20 7735 5351
email: info@nam.org.uk
web: www.aidsmap.com

By integrating services we aim to reduce the distance you may need to travel and reduce the number of appointments that you may need, by providing services in one location and providing care closer to where you live.

Your views are important to us as we want to design services that are useful to you. This survey should take about 10 minutes to complete.

Many thanks for agreeing to take part in this survey.

Accessing sexual health services at your local doctor’s practice (GP practice)

1. How happy would you be to use your local doctor’s practice (GP) for contraception services? (please circle)

Very Happy Happy Unhappy Would not use Do not need

2. How happy would you be to use your local doctor’s practice (GP) for testing and treatment of sexually transmitted infections (STIs)? (please circle)

Very Happy Happy Unhappy Would not use Do not need

3. Tell us more – what do you think about using sexual health services from your local doctor?

Accessing sexual health services at a different doctor’s practice (GP practice)

4. If available in your local town, how happy would you be to use a dedicated sexual health clinic (providing both contraception and STI testing & treatment service) held at a doctor’s practice? This may be provided by your doctor or another local doctor/nurse. (please circle)

Very Happy Happy Unhappy Would not use Do not need

5. Tell us more – what do you think about using a dedicated sexual health clinic from a doctor’s practice?

6. How far would you be prepared to travel (by car or public transport) to use this dedicated sexual health clinic? (please circle)

Up to15mins up to 30mins up to 45mins up to 60mins Over 1hour

7. Which days of the week would you prefer to use this dedicated clinic? (Please tick top 3 preferences)
Monday• Tuesday• Wednesday• Thursday•

Friday• Saturday• Any •

8. What time of day would you prefer to be able to use this sexual health clinic? (please circle)

9am-12pm 12-2pm 2-4pm 4-6pm 6-8pm

Other (please specify):

Accessing sexual health services from a pharmacy (e.g. Boots or Lloyds)

9. How happy would you be to use your local pharmacy for emergency oral contraception (morning after pill)? (please circle)

Very Happy Happy Unhappy Would not use Do not need

10. How happy would you be to use your local pharmacy for testing and treatment of sexually transmitted infections (STIs)? (please circle)

Very Happy Happy Unhappy Would not use Do not need

11. Tell us more – what do you think about using sexual health services from your local pharmacy?

12. How far would you be prepared to travel (by car or public transport) to use sexual health services in pharmacy? (please circle)

Up to 15mins up to 30mins up to 45mins up to 60mins Over 1hour

13. What time of day would you prefer to be able to use sexual health services in pharmacy? (please circle)

9am-12pm 12-2pm 2-4pm 4-6pm 6-8pm

Other (please specify):

14. Which days of the week would you prefer to use sexual health services in pharmacy? (Please tick top 3 preferences)

Monday• Tuesday• Wednesday• Thursday•

Friday• Saturday• Any •

Accessing sexual health services from a specialist community sexual & reproductive health service

15. How happy would you be to use a dedicated sexual health service provided by specialist sexual health staff in community hospital/hospital settings? (please circle)

Very Happy Happy Unhappy Would not use Do not need

16. Tell us more – what do you think about using sexual health services based on a hospital setting?

17. How far would you be prepared to travel (by car or public transport) to use this dedicated sexual health service? (please circle)

Up to15mins up to 30mins up to 45mins up to 60mins Over 1hour

18. What time of day would you prefer to be able to use this dedicated sexual health service? (please circle)

9am-12pm 12-2pm 2-4pm 4-6pm 6-8pm

Other (please specify):

19. Which days of the week would you prefer to use dedicated sexual health service? (Please tick top 3 preferences)

Monday• Tuesday• Wednesday• Thursday•

Friday• Saturday• Any •

About you

Gender: Male • Female •

I would describe my ethnic origin as:
Asian or Asian British Mixed Other Ethnic Group
•Bangladeshi •White & Asian •Chinese
•Indian •White & Black African •Any other ethnic group
•Pakistani •White & Black Caribbean • Gypsy or Traveller
•Any other Asian background •Any other Mixed Background

Black or Black British White
•African •British
•Caribbean •Irish
•Any other Black background •Any other White background

• I do not wish to disclose this

I would describe my religion as:
• Christian • Muslim • Hindu • Sikh

• Jewish • Buddist • Not religious

• Other religion not listed __________________________ • I would rather not say

Do you consider yourself to have a physical disability: Yes• No •

Do you consider yourself to have a learning disability: Yes• No •

What is your sexual orientation:

Straight• Gay• Lesbian• Bisexual• I do not wish to disclose this•

Please specify which age group you would fall into:

15 and under • 16-17 • 18-19 • 20-24 • 25-34 • 35-39•

40-44• 45+•

What is your current employment status?

• Work full time • Work part time • Unemployed • Student/at school

• Retired • Other ____________________________

Where do you live? (Nearest town)_________________________________

Thank you for completing this questionnaire. Your responses will be used to inform the redesign of sexual health services across Hampshire.
For more information on current sexual health services visit www.getiton.nhs.uk

Please return your completed questionnaire by post to:
Kate Donohoe, Public Health,
NHS Hampshire, Omega House,
112 Southampton Road, Eastleigh SO52 5PB

Or complete the questionnaire on line by visiting www.getiton.nhs.uk

Questionnaires need to returned by Monday 29th November 2010

By integrating services we aim to reduce the distance you may need to travel and reduce the number of appointments that you may need, by providing services in one location and providing care closer to where you live.

Your views are important to us as we want to design services that are useful to you. This survey should take about 10 minutes to complete.

Many thanks for agreeing to take part in this survey.

Accessing sexual health services at your local doctor’s practice (GP practice)

1. How happy would you be to use your local doctor’s practice (GP) for contraception services? (please circle)

Very Happy Happy Unhappy Would not use Do not need

2. How happy would you be to use your local doctor’s practice (GP) for testing and treatment of sexually transmitted infections (STIs)? (please circle)

Very Happy Happy Unhappy Would not use Do not need

3. Tell us more – what do you think about using sexual health services from your local doctor?

Accessing sexual health services at a different doctor’s practice (GP practice)

4. If available in your local town, how happy would you be to use a dedicated sexual health clinic (providing both contraception and STI testing & treatment service) held at a doctor’s practice? This may be provided by your doctor or another local doctor/nurse. (please circle)

Very Happy Happy Unhappy Would not use Do not need

5. Tell us more – what do you think about using a dedicated sexual health clinic from a doctor’s practice?

6. How far would you be prepared to travel (by car or public transport) to use this dedicated sexual health clinic? (please circle)

Up to15mins up to 30mins up to 45mins up to 60mins Over 1hour

7. Which days of the week would you prefer to use this dedicated clinic? (Please tick top 3 preferences)
Monday• Tuesday• Wednesday• Thursday•

Friday• Saturday• Any •

8. What time of day would you prefer to be able to use this sexual health clinic? (please circle)

9am-12pm 12-2pm 2-4pm 4-6pm 6-8pm

Other (please specify):

Accessing sexual health services from a pharmacy (e.g. Boots or Lloyds)

9. How happy would you be to use your local pharmacy for emergency oral contraception (morning after pill)? (please circle)

Very Happy Happy Unhappy Would not use Do not need

10. How happy would you be to use your local pharmacy for testing and treatment of sexually transmitted infections (STIs)? (please circle)

Very Happy Happy Unhappy Would not use Do not need

11. Tell us more – what do you think about using sexual health services from your local pharmacy?

12. How far would you be prepared to travel (by car or public transport) to use sexual health services in pharmacy? (please circle)

Up to 15mins up to 30mins up to 45mins up to 60mins Over 1hour

13. What time of day would you prefer to be able to use sexual health services in pharmacy? (please circle)

9am-12pm 12-2pm 2-4pm 4-6pm 6-8pm

Other (please specify):

14. Which days of the week would you prefer to use sexual health services in pharmacy? (Please tick top 3 preferences)

Monday• Tuesday• Wednesday• Thursday•

Friday• Saturday• Any •

Accessing sexual health services from a specialist community sexual & reproductive health service

15. How happy would you be to use a dedicated sexual health service provided by specialist sexual health staff in community hospital/hospital settings? (please circle)

Very Happy Happy Unhappy Would not use Do not need

16. Tell us more – what do you think about using sexual health services based on a hospital setting?

17. How far would you be prepared to travel (by car or public transport) to use this dedicated sexual health service? (please circle)

Up to15mins up to 30mins up to 45mins up to 60mins Over 1hour

18. What time of day would you prefer to be able to use this dedicated sexual health service? (please circle)

9am-12pm 12-2pm 2-4pm 4-6pm 6-8pm

Other (please specify):

19. Which days of the week would you prefer to use dedicated sexual health service? (Please tick top 3 preferences)

Monday• Tuesday• Wednesday• Thursday•

Friday• Saturday• Any •

About you

Gender: Male • Female •

I would describe my ethnic origin as:
Asian or Asian British Mixed Other Ethnic Group
•Bangladeshi •White & Asian •Chinese
•Indian •White & Black African •Any other ethnic group
•Pakistani •White & Black Caribbean • Gypsy or Traveller
•Any other Asian background •Any other Mixed Background

Black or Black British White
•African •British
•Caribbean •Irish
•Any other Black background •Any other White background

• I do not wish to disclose this

I would describe my religion as:
• Christian • Muslim • Hindu • Sikh

• Jewish • Buddist • Not religious

• Other religion not listed __________________________ • I would rather not say

Do you consider yourself to have a physical disability: Yes• No •

Do you consider yourself to have a learning disability: Yes• No •

What is your sexual orientation:

Straight• Gay• Lesbian• Bisexual• I do not wish to disclose this•

Please specify which age group you would fall into:

15 and under • 16-17 • 18-19 • 20-24 • 25-34 • 35-39•

40-44• 45+•

What is your current employment status?

• Work full time • Work part time • Unemployed • Student/at school

• Retired • Other ____________________________

Where do you live? (Nearest town)_________________________________

Thank you for completing this questionnaire. Your responses will be used to inform the redesign of sexual health services across Hampshire.
For more information on current sexual health services visit www.getiton.nhs.uk

Please return your completed questionnaire by post to:
Kate Donohoe, Public Health,
NHS Hampshire, Omega House,
112 Southampton Road, Eastleigh SO52 5PB

Or complete the questionnaire on line by visiting www.getiton.nhs.uk

Questionnaires need to returned by Monday 29th November 2010

Many people with HIV also have hepatitis B or hepatitis C. This is often referred to as ‘co-infection’. The liver disease that these infections can cause is now a major cause of illness and death in co-infected patients.

There’s a lot you can do to protect yourself against these viruses. They can also be treated.

There is a lot of information available about hepatitis B and hepatitis C. A good place to start is the section on hepatitis on our website namlife.org, or you could visit the hepatitis topics pages on our website aidsmap.com, to see all our hepatitis publications.

NAM also produces a free booklet on HIV and hepatitis.

In the UK, the Hepatitis C Trust offers support and information on all aspects of living with hepatitis C through their helpline: 0845 223 4424; the British Liver Trust offers support and information on all types of liver disease, you can contact them on 0800 652 7330.

HIV and hepatitis C – the epidemic in France

Approximately 25% of HIV-positive patients in France are co-infected with hepatitis C. Researchers have looked at the characteristics of these patients and the implications of co-infection.

A total of 1175 people were included in the analysis. Their HIV profile was reasonably good. The average CD4 cell count was 442, 72% were taking HIV treatment and 68% had an undetectable viral load.

Most of the patients had been infected with hepatitis C through injecting drug use.

A variety of tests were used to assess the liver damage caused by hepatitis C. Depending on which test was used, between 27 and 46% of patients were found to have cirrhosis – permanent scarring of the liver.

Just over half the patients received hepatitis C treatment. But responses were poor. Only 34% of patients who were taking treatment for the first time cleared their hepatitis C infection.

A total of 49 patients died, and 41% of these deaths were directly attributable to hepatitis C.

Having cirrhosis or a low CD4 cell count increased the risk of death.

Some people experience depression as a symptom of hepatitis C or a side-effect of its treatment. The researchers found that treating this not only improved patients’ mood, but also helped with other symptoms such as tiredness.

HIV and hepatitis C – predicting the success of treatment

Researchers have developed a new tool that helps them to predict which patients will respond to treatment.

It’s based on tests that can be performed as part of routine care. None of them requires a liver biopsy. The tool can be downloaded for free here.

The researchers used four test results to predict outcomes:

• hepatitis C viral load.
• hepatitis C genotype.
• liver stiffness.
• genetics.

All four of these factors have a role in predicting response to treatment.

It’s already well known that people with a high hepatitis C viral load are less likely to respond to treatment.

Poorer responses to therapy are also seen in people who are infected with hepatitis C genotypes 1 and 4.

But liver stiffness is a new predictor of treatment success. It’s assessed using a test called FibroScan. This involves placing a small instrument against the skin above the liver. The test can tell how damaged the liver is and if a person has fibrosis or cirrhosis.

Finally, it’s been shown that people who have a certain genetic mutation are less likely to respond to hepatitis C treatment.

The researchers tested the accuracy of their tool on two groups of co-infected patients in Spain. It was shown to be highly reliable.

Hepatitis B – vaccination

Another virus that can cause serious liver problems is hepatitis B, and many people with HIV are co-infected with hepatitis B.

A vaccine is available against hepatitis B. It is recommended that everyone who is HIV-positive receives this vaccine.

It’s provided in three doses over a six-month period via injections. To make sure that you’re protected against the virus, it’s important to have all three injections.

After vaccination, your immunity to hepatitis B will be checked regularly to see if you need a ‘booster’ dose.

However, some people don’t return to the clinic for all three doses of the vaccine. Researchers therefore wanted to see if it was possible to provide the vaccine in a shorter, accelerated time period.

Their study involved drug users. Half received the vaccine over the normal six-month period, the others over two months.

Overall, about 75% of people received all the required doses. There was no real difference in the proportion of patients in the standard and accelerated vaccination arms who completed treatment.

But people who injected drugs were more likely to receive all three doses of the vaccine if they were in the accelerated arm (75 vs 66%).

Seeking professionals’ views on new NICE testing guidance

The National Institute for Health and Clinical Excellence (NICE) is developing guidance on increasing HIV testing among men who have sex with men (MSM). It is intended for commissioners, NHS practitioners, local authorities and the wider public, private, voluntary and community sectors in England.

NatCen (National Centre for Social Research), Sigma Research and NAM are testing this guidance with practitioners in England.

If you work with or influence the lives of MSM, in health, social care, policy or advocacy, we need to hear your views. Please complete our online survey.

You can find out more about the survey, and complete it online, on the Sigma Research website here. We really value your input.

The survey closes at 5pm on Wednesday 10th November.

Staying free of hepatitis C

This feature first appeared in our regular publication HIV treatment update and is now available on our website.

HIV & the criminal law

HIV & the criminal law is now available to buy. Launched as a web resource during the International AIDS Conference in Vienna, the print edition is now in stock.

It explores the full range of issues relating to the criminalisation of HIV exposure and transmission around the world, with information on current laws and practice internationally.

Produced in a handy A5 size, HIV & the criminal law is priced at £34.95, but can currently be bought at a special introductory price of £29.95.

Contact us for more details, or to place an order, on 020 7840 0050 or by emailing info@nam.org.uk.

HIV & hepatitis

A new, revised edition of NAM’s patient information booklet, HIV & hepatitis, is now available online and in print.

If you work in a clinic or support group in the UK, you can order printed copies of our booklets for free for your clients and patients through our free booklet scheme.

Contact us for more details on 020 7840 0050 or by emailing info@nam.org.uk.

HIV & hepatitis is also available online in French, German, Italian, Portuguese, Russian and Spanish.

Facebook

Join our Facebook network – and ask your friends to join us too!

For more details, please contact NAM

tel: +44 (0)20 7840 0050
fax: +44 (0)20 7735 5351
email: info@nam.org.uk
web: www.aidsmap.com

There have been some big improvements in HIV treatment and care in recent years. Thanks to these, the aim of treatment for most patients is an undetectable viral load.

An important treatment option for those who have a lot of experience of HIV therapy is the protease inhibitor darunavir (Prezista).

Its power is boosted by taking it with a small dose of a second protease inhibitor called ritonavir (Norvir).

Clinical trials showed that including darunavir in an HIV treatment option was safe and effective in very treatment-experienced patients. The best results are seen when it’s combined with other drugs that work against HIV. Darunavir has also been approved for people starting HIV treatment for the first time.

But people in clinical trials usually receive a lot of support and are intensively monitored. Drugs don’t always have such good results when used in routine HIV care.

Researchers therefore wanted to see how effective darunavir was at suppressing viral load in 130 treatment-experienced Swiss patients who had received the drug as part of their HIV therapy.

The patients had taken a lot of anti-HIV drugs in the past. Many had HIV with some form of resistance to darunavir.

However, after a year of treatment, viral load was undetectable in 80% of patients. This compared to 45% in clinical trials. Having a detectable viral load was associated with poor treatment adherence, and with previous treatment with the protease inhibitors fosamprenavir or amprenavir (Agenerase or Telzir) and saquinavir (Invirase).

The drug was safe – only a small number of patients stopped taking it because of side-effects.

Read the full news story on our website here or visit the journal website to view the original article here.

HIV treatment – saquinavir side-effect warning
All medicines – including those used to treat HIV – can cause side-effects.

Some protease inhibitors have been associated with an irregular heartbeat. It’s already known that this is the case with saquinavir/ritonavir.

Now drug regulatory authorities in both the US and Europe have issued a strengthened warning about the heart rhythm disturbances that can be caused by ritonavir-boosted saquinavir (Invirase).

Although this side-effect is rare, it’s now recommended that all patients should have an ECG examination to monitor the health of their heart before they start treatment with saquinavir.

Medicine regulators in the US have also made specific recommendations about heart rhythm and treatment with saquinavir.

They recommend that anyone taking the drug should: “Seek immediate care if you experience an abnormal heart rate or rhythm or other symptoms including dizziness, lightheadedness, fainting or heart palpitations.”

European regulators have also made specific recommendations about saquinavir doses for those starting HIV treatment for the first time.

These state that the dose of saquinavir for the first week of treatment will be reduced from 1000mg twice daily to 500mg twice daily. This dosage adjustment is not necessary in patients who are switching from other antiretroviral drugs; the European Medicines Agency says the risk of an irregular heartbeat is greatest in people who have never taken antiretroviral drugs before.

For more information on side-effects you can read our information booklet on our website here.

HIV and sexual health – treatment of syphilis
High rates of sexually transmitted infections, including syphilis, have been seen in people with HIV.

Syphilis is a bacterial infection which can cause serious health problems if left untreated.

However, it can be successfully treated with antibiotics.

The usual treatment is injections into the muscle (usually the buttocks) of a long-lasting form of penicillin called benzathine penicillin G. Other antibiotics also work against syphilis.

The intensity of treatment varies according to the stage of syphilis – for example patients with syphilis that’s affecting the brain (neurosyphilis) are treated with a different type of penicillin that’s administered intravenously.

There have been reports of the standard treatments for syphilis not working as well in people with HIV. Because of this some doctors are uncertain about the best way to treat the infection.

US guidelines say that HIV-positive patients with syphilis should receive the standard therapies but with more intensive follow-up.

But a team of researchers have found that this recommendation has a very poor evidence base.

They could only find 23 studies that provided an in-depth analysis of syphilis therapy for patients with HIV. Only two of these studies were ranked as high quality.

Reported treatment failure rates were as high as 22% for early syphilis, 31% for latent syphilis and 28% for neurosyphilis. These rates are much higher than the 3 to 10% seen in HIV-negative patients.

The researchers don’t rule out the possibility that standard syphilis therapy is less effective in patients with HIV. But they think it’s more likely that there are other reasons for the high failure rate in these studies, for example, reinfection with syphilis.

There’s more information on syphilis and its treatment in our HIV Treatments Directory, now available on our website here.
HIV & the criminal law
HIV & the criminal law is now available to buy. Launched as a web resource during the International AIDS Conference in Vienna, the print edition is now in stock.

It explores the full range of issues relating to the criminalisation of HIV exposure and transmission around the world, with information on current laws and practice internationally.

Produced in a handy A5 size, HIV & the criminal law is priced at £34.95, but can currently be bought at a special introductory price of £29.95.

Contact us for more details, or to place an order, on 020 7840 0050 or by emailing info@nam.org.uk.

A gap in the facts?
Women for Positive Action is an organisation that campaigns for better inclusion of women’s needs into HIV research and care.

Dr Sharon Walmsley, WFPA Faculty Member, recently wrote an article for us on the under-representation of HIV-positive women in clinical trials.

This feature first appeared in our regular publication HIV treatment update and is now available on our website.

HIV & hepatitis
A new, revised edition of NAM’s patient information booklet, HIV & hepatitis, is now available online and in print.

If you work in a clinic or support group in the UK, you can order printed copies of our booklets for free for your clients and patients through our free booklet scheme.

Contact us for more details on 020 7840 0050 or by emailing info@nam.org.uk.

HIV & hepatitis is also available online in French, German, Italian, Portuguese, Russian and Spanish.

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For more details, please contact NAM

tel: +44 (0)20 7840 0050
fax: +44 (0)20 7735 5351
email: info@nam.org.uk
web: www.aidsmap.com

HIV treatment and bone health
HIV treatment and resistance
HIV and women
HIV and lung disease
HIV treatment and bone health
New European research suggests that treatment with tenofovir (Viread, also in the combination pills Truvada and Atripla) results in more bone loss than therapy with abacavir (Ziagen, also in the combination pills Kivexa and Trizivir).

Increasing attention is being paid to bone density in patients with HIV.

The virus itself can cause loss of bone, but there’s now quite a lot of research showing that this can also be a side-effect of HIV treatme

Long-term adherence
Hepatitis C treatment for women with HIV and hepatitis C
Nevirapine switch possible at any CD4 cell count
HIV and the law
Long-term adherence
The longer a person taking HIV treatment keeps their viral load undetectable, the lower the risk of it rebounding, new research shows.

The Canadian study involved 1305 patients who were starting HIV treatment for the first time.

Treatment reduced viral load to undetectable levels in all the patients.

However, it subsequently rebounded in 21% of patients.

One of the factors associated with an increase in viral load was the amount of time that it had been suppressed to undetectable levels.

The risk of rebound was highest during the first year of treatment. But after that, the longer that viral load was suppressed to undetectable levels, the lower the risk of it increasing.

This was true at all levels of adherence.

Each month of viral suppression reduced the risk of rebound by about 8%.

This suggests that the consequences of missed doses may be less severe the longer a patient has been taking treatment.

Nevertheless, the researchers emphasise that people taking HIV treatment should aim to take all their doses correctly.

Even after taking into account the amount of time viral load was suppressed, those who took 95% or more of their doses were less likely to experience an increase in viral load than those with the poorest adherence.

There’s help available to you, to help you take your HIV treatment correctly. You can find out why adherence is so important in the NAM booklet on this subject. There are also tips to help you take your treatment, and information on where you can turn to for support.

Hepatitis C treatment for women with HIV and hepatitis C

Women with HIV and hepatitis C are more likely to experience side-effects that lead to stopping or changing hepatitis C treatment than co-infected men, report US investigators.

They reviewed the results of three big trials looking at the safety and effectiveness of hepatitis C treatment in people with HIV.

Women were much more likely to stop treatment because of side-effects than men (24 vs 16%). In addition, more women than men experienced side-effects that led to treatment being changed (61 vs 48%).

Taking HIV treatment that included a non-nucleoside reverse transcriptase inhibitor (NNRTI) was associated with women stopping treatment.

Efavirenz (Sustiva, also in the combination pill Atripla) is an NNRTI that can cause mood and sleep problems. Higher blood concentrations of this drug have been seen in women. The investigators suggest that this may explain why therapy with NNRTIs was associated with treatment discontinuations in women.

Visit our website for more information on hepatitis C.

Nevirapine switch possible at any CD4 cell count
People taking HIV treatment who have an undetectable viral load can safely switch treatment to nevirapine (Viramune) when their CD4 cell count is at any level.

This is the latest advice from European drug regulators.

Nevirapine is an NNRTI. Patients who have a higher CD4 cell count when they start treatment with the drug have a risk of developing serious liver problems or an allergic reaction.

Therefore, wo

Now Spanish investigators have published a study showing that the consequences of swine flu were no more serious for people with HIV than for HIV-negative patients.

The researchers reviewed the medical records of 585 patients who were admitted to hospital because of swine flu. Twenty-six of these people were HIV-positive.

Most of the HIV-positive patients were taking HIV treatment. Their average CD4 cell count was over 500 and 84% had an undetectable viral load.

There were no differences in the types of swine flu symptoms between the HIV-positive and HIV-negative patients.

Both groups of individuals started to get better two-and-a-half days after they were admitted to hospital, and there was no difference in the length of their stay in hospital.

Similar rates of complications were seen in the two groups of patients. Three of the HIV-negative patients died, but all the HIV-positive patients made a full recovery.

The researchers describe these results as “remarkable”.

CD4 cell count and Kaposi’s sarcoma
Rates of the AIDS-defining cancer, Kaposi’s sarcoma, fell dramatically after the introduction of effective HIV treatment, US research has shown.

But the same study showed that the cancer is now being found more frequently at higher CD4 cell counts. The researchers think that is another reason why patients should start HIV treatment promptly.

Researchers from the US military looked at rates of Kaposi’s sarcoma in HIV-positive military personal between 1985 and 2008.

Compared to the period before 1990, those receiving care after 2002 had a 72% reduction in their risk of developing the cancer.

However, Kaposi’s sarcoma appeared to be occurring at higher CD4 cell counts. Before 1990, only 18% of patients had a CD4 cell count above 350 when the cancer developed. However, after 2002 this had increased to 35%.

Nevertheless, the researchers found that a higher CD4 cell count reduced the risk of the cancer.

In addition, patients with a CD4 cell count below 350 were about eight times more likely to develop Kaposi’s sarcoma than those with a CD4 cell count above this level.

The researchers found some evidence that, among patients with a CD4 cell count above 350, those taking HIV treatment were less likely to be diagnosed with the cancer.

HIV and kidney problems
Few HIV-positive patients in Europe have end-stage kidney disease, researchers have found.

Over 60,000 patients were included in the study, but just 122 patients had kidney disease that was so serious it required dialysis or a transplant.

Nearly all the patients were taking HIV treatment, 88% had a viral load below 500 copies/ml, and average CD4 cell count was around 350.

Most of the patients with serious kidney problems were men, and the majority were of black race.

HIV-related kidney disease was the biggest single cause of serious renal problems.

A total of 26 patients had had a kidney transplant. Eight of these had experienced organ rejection, but all the patients were still alive.
Meet Jackie

Find out more about the newest member of our team, Jackie, who has recently started working as NAM’s Communities Engagement Officer.

You can read about Jackie and her plans for the role in our blog.

Life check

How much do you know about living with HIV? Test your knowledge with our HIV life check.

Will Craig reach Vienna?
Our heroic cyclist, Craig, is due to arrive in Vienna today, at the end of his massive cycle ride from London (2200 miles!), raising funds for NAM – thanks to your generosity he reached his £1500 target and decided to raise the stakes to £2000!

You can sponsor Craig and read more about his incredible journey at www.justgiving.com/vienna.

Or if you would like to find out more about raising money for NAM, visit our fundraising webpages or contact us at info@nam.org.uk or 020 7840 0050.

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