Hepatitis C. Condoms get another endorsement! In July the news was abuzz that hepatitis C is now known to be efficiently transmitted by anal sex. Previously it was thought that sex was inefficient and needles were virtually the main way.
Telaprevir (Incivek®) and boceprevir (Victrelis®) have been approved but only in combination with the older medications which are hard to take—so no break yet from the old regimen! These new medications offer hope for those resistant to the main treatment. Possibly, they also offer pieces of future regimens that will be only oral and be more tolerable.
Here is a summary of important presentations at July’s International AIDS Conference in Rome. I used the summary from Clinical Care Options website for HIV specialists as the main source.
Prevention by treatment of the positive partner. This was a study in 5 regions and 4 continents followed for 1.7 years. 1763 couples entered, where the focus was on the positive partner with treating immediately with a higher CD4 or waiting for a lower CD4 to begin treatment. 97% were heterosexual couples. Of course they were encouraged to use safe sex so both groups had very low transmission rates. The early treatment group had 1/3% transmissions/year and the late treatment group had 2.2%, so there was a 96% reduction in likelihood of HIV transmission among serodiscordant couples if the positive partner was treated immediately. These transmissions are the result of unsafe sex. So treating the positive partner reduces risk of transmission to the negative partner.
Prevention by treating the negative partners of 4,747 couples. The Partners Pre-exposure prophylaxis study showed that taking tenofovir (Viread®) daily decreased risk by 62%. The pills worked well in women and men. This study was randomized (you could not predict which pills you were going to take (active medication or placebo) and double blinded (neither the clinic staff, nor the patient knew which they were taking). It was performed similarly to the study above with encouraging safe sex which is great in preventing transmission, but about 1% of the women became pregnant, and 1/3 had sex outside of the relationship (safe sex advice was not followed in some).
There were some promising medications discussed: Lersivirine (both similar in strength to Efavirenz), Dolutegravir and Elvitegravir (similar in strength to Raltegravir).
Very early treatment of HIV: Treating for a year, as close to the moment the infection starts, has these benefits: having a lower viral load maximum (set point), CD4 later will go down slower and can rise better, but there was no difference when you consider the time on therapy, i.e. when those not treated at the beginning were finally treated, they could make up this drop. Early treatment did not cause resistance to emerge. Treating the same types of patients for only 12 weeks had no such benefits. Based on this study some might want to get treatment for at least a year as soon as they know they are infected.
Osteoporosis and fractures. The risks for these are: higher age, being Anglo, smoking, having diabetes, being too thin, chronic kidney disease, and having hepatitis C. This study seemed to implicate tenofovir (Viread®), using boosted protease inhibitors, or being on lopinavir (Kaletra®). This risk was not associated with the other Nucs such as abacavir (Ziagen®) or other protease inhibitors. Please note that to find these small differences, they looked at over 56,000 Veterans Administration patients and only 2% had fractures over the 10 years of data looked at.
Tenofovir (Viread®) seemed to be correlated with chronic kidney disease more than other medications. This report is a confirmation of past research. Chronic kidney disease is associated with diabetes, older age, high fats in blood, being female, and having a low CD4. This was an incidence of about 1%/year chance of having this condition in this study of 2,693 patients followed for 3.4 years. Remember that tenofovir is also in Atripla® and Truvada®. Ask about your kidneys if you are on these medications even though this problem is uncommon.
HIV dementia still occurs even though we have great medications to control the HIV. Some medications do not prevent it or treat it well. One investigator has studied which medications will do a better job penetrating the brain cells, treating the dementia, or preventing it. He came up with scores for the medication. Sadly, these scores, when applied to patients do not seem to make a difference in the study presented.
IRIS is Immune Reconstitution Inflammatory Syndrome which begins when a person has a low grade infection (maybe they don’t even feel it) and flares up then they start antivirals. The powerful antivirals causes their bone marrow to recover very well and white cells attack the low grade infection causing swelling and inflammation suddenly. This can happen in the eyes, brain, lungs, and other places. The risk is highest when the CD4 is less than 100.
A recent study showed that if you start antivirals sooner when you are also just starting TB treatment, then you may get a large flare of the TB. About 4% died from the flare. On the other hand, if you don’t treat the HIV early enough, then the patient can die from AIDS-related causes. Starting antivirals after 8 weeks of TB treatment caused fewer problems than at 4 weeks.
Another study showed that early antiviral treatment of HIV at 4 weeks had more IRIS cases than waiting till the intensive phase of TB treatment was over (usually 8-12 weeks depending on the patient’s response) and that this last method had the same number of IRIS cases as treating HIV after the year or so of TB treatment was finished.
Safe sex or no sex is best. Get tested regularly. Don’t miss medications. See your doctor regularly.
Daniel Pearce, D.O., FACOI, AAHIVMS
HIV Specialist Physician, Riverside County Public Health Department
HIV Specialist Physician, AIDS Healthcare Foundation, and Desert AIDS Project
Associate Clinical Professor of Internal Medicine, Assistant Director of Medical Affairs, Center for Advancement of Drug Research and Evaluation (CADRE) Western University, College of Osteopathic Medicine of the Pacific