Compiled by Robert Fieldhouse
Fatter people respond ‘as well’
to HIV drugs
Body
mass index (BMI) does not influence people’s response to HAART, according
to a study of US patients.
Body mass index - our height-weight ratio - can affect the way drugs are distributed
into tissues resulting in variable levels of ARV drugs.
US researchers looked at BMI and its relationship to first-line HIV therapy,
to test whether people with a higher BMI had a reduced response to their drugs.
The proportion of people achieving an undetectable viral load or a CD4 cell
count increase greater than 100 cells did not differ statistically as BMI
increased.
Increasing age, male gender, and a lower viral load at the point of starting
therapy were associated with achieving an undetectable viral load, the researchers
showed.
“Although evidence from other sources suggests untreated overweight
and obese persons might be expected to respond better than normal weight patients,
we were unable to detect any further improvement among overweight and obese
patients over the excellent responses achieved by normal weight patients,”
said the researchers
“These data suggest the potency of current HAART regimens is adequate
for normal weight to obese persons, although additional pharmacokinetic and
clinical data among overweight and obese patients would be desirable,”
the investigators added.
JAIDS 2006;43:35-41.
Body fat loss common in women with HIV
Body fat loss is common in women living with HIV aged 33-45, according to
a new US study of 183 women. Body fat loss was a common feature of lipodystrophy
syndrome, the study found.
Compared to a similar number of HIV negative women, women with HIV experienced
more fat loss. Twenty-eight per cent of women with HIV experienced fat loss
compared with only four per cent of the HIV negative women.
Around 60 per cent of both positive and negative women experienced fat accumulation
around their middles. However, women with HIV who had central fat accumulation
were significantly less likely to have peripheral fat loss.
This lead the researchers to conclude that peripheral fat loss was “not
associated with reciprocally increased visceral adipose tissue or trunk fat”.
JAIDS 2006;42:562-571
Poor male hygiene ups HIV risk
Washing the penis and keeping it dry cuts the risk of HIV infection in both
circumcised and uncircumcised men.
Researchers from Ealing Hospital, London, suspected that penile wetness would
increase HIV acquisition risk, and that keeping the area under the foreskin
dry may reduce that risk.
To test the theory they studied 386 uncircumcised South African men. They
found half had some degree of wetness on their penises. Around 80 per cent
were judged to be slightly wet, 19 per cent as wet, and two per cent as very
wet.
By comparison, only one of 36 circumcised men had wetness.
Factors associated with penile wetness were younger age, low level of education,
low income, higher lifetime numbers of sexual partners and not washing after
sex.
Two thirds of the men defined as having wet penises were HIV positive, compared
to 45.9 per cent of those with no wetness.
The authors noted that HIV prevalence among uncircumcised men without penile
wetness was close to that of circumcised men (42.9 per cent).
Although many factors associated with penile wetness were poverty-related,
the researchers recommended provision of more information, education, and
communication programmes that included advice on pre- and post coital washing.
Interventions to improve genital hygiene may also be effective in reducing
HIV infection risk.
JAIDS 2006; 43: 69-77, 117-118
Persistent low-level viral load linked to
treatment failure
People on therapy with a low viral load for at least three months may
be at greater risk of treatment failure than those whose virus remains undetectable.
Researchers looked at the records of 362 people on HAART who had been undetectable.
They found more than one in four had a persistent viral load of between 50
and 1,000 copies while on therapy.
People were monitored for at least 12 months and visited their clinic every
three months.
Persistent low-level viral load occurred on average 22 months after starting
treatment, and lasted for an average of 6.4 months.
After 29.5 months, patients with persistent low-level virus had a higher rate
of virological failure (39.7 vs 9.2 per cent).
And the average time to virological failure was 68.4 months for people with
persistent low-level virus, compared to more than 72 months for patients without
persistent virus.
A persistent viral load above 400 copies and a history of prior antiretroviral
therapy predicted virological failure (defined as two consecutive viral loads
greater than 1,000 copies).
Researchers recommended that patients with persistent low viral loads should
discuss treatment optimisation and interventional studies with their doctors.
HIV Medicine 7(7): 437-441. October 2006.
Liver, lung and heart disease leading causes of non-Aids deaths
Eating moderate quantities of dairy foods does not make HIV-related diarrhoea
worse, a new study has found.
Chronic diarrhoea is common among people with HIV in the HAART era and people
are often urged to avoid products containing lactose. But there is little
evidence to support this dietary strategy.
In a study of 49 HIV positive people with diarrhoea, researchers compared
stool weight in the eight hours following drinking low-fat milk (12g of lactose)
or lactose-free milk. Lactose was considered not to have had a harmful effect
if the stool weight did not differ by more than 167g in those that drank the
low fat milk. All but one participant was male and the average age was 42.
The average CD4 count was 390 and average viral load was 112 copies. Thirty-nine
were taking HAART.
Use of the lactose-containing milk was associated with a slight decrease in
stool weight from 167.6g to 126.3g. There was also a slight increase in stool
weight among those drinking the lactose-free milk.
“Given the risks of malnutrition and osteopenia in this population,
practitioners may wish to encourage their HIV patients with diarrhoea to include
moderate quantities of dairy products in their diets,” the authors concluded.
Arch Intern Med 2006; 166: 1178-1183
Needle-free device reduces T-20 skin reactions
A
study into using a needle-free injection device to administer T-20 through
the skin into body fat produced fewer injection site reactions than standard
needles.
The device, Biojector 2000, uses air pressure to propel medication through
the skin into body fat. Participants either continued with standard needles,
switched to insulin needles or the Biojector 2000.
Patients were assigned the Biojector if they had moderate-to-severe injection
site reactions; needle phobia; needle fatigue or struggled using syringes.
Adherence, tolerability and satisfaction was assessed at various stages.
More than nine out of 10 (92 per cent) people using the Biojector remained
on T-20. The main reasons for stopping T-20 were injection site reactions
(three per cent) or lack of virological control (two per cent). Only two per
cent found the Biojector too hard to use.
Adherence to T-20 among those using the Biojector improved over the course
of the study (69 per cent at the start and 85 per cent after 6 months). Some
patients switched to the Biojector and reported improved satisfaction and
fewer injection site reactions compared to using needles.
Six months after the switch, three quarters of those using the Biojector 2000
said they preferred it to needles. People using insulin syringes were most
likely to discontinue T-20.
16th IAC, Toronto, 13-18 August, 2006.
Abstract TUPE0147/16696.
Oral thrush linked to HIV viral load
People
with higher viral loads appear at to be at greater risk of developing oral
thrush.
The US study shows viral load plays a much greater role than previously thought
in susceptibility to oropharyngeal thrush, caused by Candida albicans.
CD4 count was a less useful marker for the development of thrush, and factors
such as race and age factors appeared to have little influence.
JAIDS 2006;42:578-583.
Hospital linked with mistakes in HIV medications
One in four HIV positive people admitted to a large US clinic experienced
errors in their antiretroviral prescriptions during their stay, a study has
found.
The errors occurred at Johns Hopkins Clinic in Baltimore, despite the hospital’s
modern computerised order system.
Researchers investigated every person admitted to the clinic on HIV medication
over a one year period, checking records for potential errors
Out of the 209 admissions they identified 61 uncorrected errors from 54 patients.
The most common error concerned frequency of dose, occurring in 34 patients.
Eighteen of these errors were attributable to failure to appropriately adjust
dosages for those with kidney dysfunction.
The second most common mistake was combining antiretroviral drugs with a contraindicated
drug which occured in 12 patents). Eight patients had drugs missed out of
their combos and seven experienced unexplained delays.
The authors concluded: “HIV infected patients receiving HAART are at
substantial risk for antiretroviral medication errors at the time of hospitalisation.
More needs to be done to ensure that these patients receive appropriate therapy
during their inpatient stay.”
While the authors noted that general healthcare providers were often unfamiliar
with antiretroviral medications, they also pointed out that errors with HIV
meds, even when promptly corrected, could have serious long-term implications.
Clinical Infectious Diseases 43(7): 933-938. October 1, 2006.
Women at increased risk of certain side effects
Women with HIV are more likely to develop lactic acidosis and hypersensitivity
reactions compared to men.
A large Canadian study looked at gender differences in the rate of metabolic
side effects of HAART such as elevated cholesterol or triglycerides.
After starting HAART, there was little difference between men and women in
the overall rate of hyperglycaemia, elevated cholesterol, or body fat changes.
However, women with HIV were twice as likely to develop symptomatic lactic
acidosis (5.2 vs 2.2 per cent), which is caused by a build up of lactic acid
and can lead to nausea, abdominal pain and difficulty breathing.
The overall incidence of hypersensitivity reactions with antiretroviral therapy
was also higher in women than in men (7 vs 4 per cent). The NNRTI nevirapine
(Viramune) caused the majority of all hypersensitivity reactions.
The researchers said: “The high frequency of metabolic complications
observed in both sexes emphasises the importance of safer HAART regimens and
timely management of side effects”
J Med Virol 2006:78:1158-1163.
One in six interrupts HAART during first
two years
Data from a large group of people living with HIV in Europe show one in six
interrupts their treatment within two years of starting therapy.
Dr Kholoud Porter, of the MRC Clinical Trials Unit, London, assessed the consequence
of HAART interruption as part of the CASCADE (Concerted Action on Seroconversion
to AIDS and Death in Europe) cohort.
Of 1,551 people starting HAART, 299 interrupted treatment. The average interruption
lasted 189 days. Women were far more likely to interrupt their therapy.
People interrupt HAART for many reasons: drug-related side effects; interrupted
access to therapy; other clinical and social factors.
During interruptions, the average CD4 loss was 94. The data indicate interruption
carries greater risk for people aged over 40, those who had had CD4 counts
below 200 before starting therapy, and those with limited CD4 gains on therapy.
Interruptions may be safe for people with a well-retained immune system, but
caution and close monitoring are essential.
JAIDS 2006;42:554-561.
Kids with HIV have reduced response to childhood
vaccines
Many
children with HIV taking antiretroviral therapy lose antibodies stimulated
by vaccines.
This means they may be less protected against diseases like measles and mumps
and viruses such as varicella zoster and cytomegalovirus, according to latest
research.
Researchers from Amsterdam said lifelong immunity to measles, mumps and rubella
(MMR) is typically maintained in HIV negative people, but this does not seem
to be the case for all children with HIV.
Children with HIV seem to have a weaker and more transient response to vaccinations
and it remains unclear whether HAART can stop or reverse the loss of specific
protective antibodies.
Researchers studied 59 children who had received the MMR vaccine before they
started therapy. At the start of the study less than half (43 per cent) of
the children had antibodies to all three of these pathogens.
Antibodies to measles were lost in 40 per cent of children after they started
HAART. This also was the case for mumps (38 per cent) and rubella in (11 per
cent). A number of the children were given the MMR vaccine again.
Although it is unknown if the loss of specific antibodies presents a real
threat, the researchers concluded that: “Regular testing for the loss
of specific antibodies in children with HIV infection seems mandatory.”
Pediatrics 2006;118:e315-e322.
US moves toward universal HIV testing
Everyone in the US between the ages of 13 and 64 should be offered routine,
voluntary HIV testing, according to new guidelines from US Centers for Disease
Control and Prevention (CDC).
Around one in four of America’s one million people living with HIV are
unaware of their infection. People unaware of their infection are significantly
more likely to transmit HIV than those who know their HIV status. The CDC
calculates it could reduce new infections by 30 per cent if routine testing
was introduced for everyone.
Under its recommendations people would be allowed to ‘opt out’
of HIV testing but only following appropriate counselling. People at greatest
risk of HIV infection should be tested annually, it suggests.
Doctors should also be trained to spot symptoms of acute HIV infection, which
resemble flu and other viral illnesses, before sero-conversion and offer viral
load tests.
Mother-to-child HIV transmission has declined dramatically in the US since
1991, but 240 cases still occur each year.
The authors advise that HIV screening be part of routine prenatal tests for
all pregnant women during their first three months of pregnancy and in the
final three months.
If the woman's HIV status is still unknown at the time of labour, she should
be screened with a rapid HIV test, and receive antiretroviral prophylaxis,
the guidelines said.
Newborn babies should also be tested as soon as possible so that prophylaxis
can be started if indicated.
MMWR CDC Surveill Summ 2006.
EU licensing application made for three-in-one pill
The advent of a three-in-one daily antiretroviral drug in the European Union
moved a stage closer this month, as three major pharmaceutical companies (Bristol-Myers
Squibb, Gilead Sciences, and Merck & Co) announced the submission of a
marketing authorisation application for its co-formulated pill to the European
Medicines Agency.
Atripla is the first fixed-dose once daily combination HIV tablet containing
the NNRTI efavirenz (Sustiva), the nucleoside analogue emtricitabine (Emtriva)
and the nucleotide analogue tenofovir (Viread). It has been available in the
US since the summer when it was approved by the FDA
