Early diagnosis of HIV infection and effective treatment can be the difference between life and death, writes Judy Hobson
Thanks to the introduction of highly active antiretroviral therapy in the late-1990s, where doctors use not just one but a combination of drugs to target the HIV virus and slow down its replication, those diagnosed early can now expect to have a normal lifespan.
There are people in their 70s and 80s in the UK with HIV, according to HIV charity, the Terrence Higgins Trust (THT), and many infected during the 1990s are now in their 50s. Indeed, since 2000 there has been a four-fold increase in people aged 50 and over accessing HIV care.
Jason Warriner, THT’s clinical director, says: “Over the last decade, the average lifespan of someone with HIV, provided they are diagnosed and started on treatment in good time, has risen from 30 years from time of diagnosis to 46 years. This means we’re now at the stage where someone diagnosed with HIV has every chance of living well into old age.”
Every day in the UK, 20 people are diagnosed with HIV. The Health Protection Agency estimates that by 2012 there will be more than 100,000 people with diagnosed and undiagnosed HIV. Worryingly, 25,000 are unaware of their HIV-positive status and may well pass it on to their sexual partners.
With Aids no longer in the headlines, experts fear complacency has grown among gay men. Over the past three years there has been a sharp increase in the number of new diagnoses among men who have sex with other men. The largest-ever annual number of 3,080 was recorded last year.
Prevalence among gay men in the UK is estimated to be 5 per cent. In London, it is put at 9 per cent, the equivalent of one in eleven, but Dr Michael Brady, an HIV consultant at London’s Kings College Hospital, believes it to be as high as one in seven.
To address complacency among gay men, the Department of Health is using social media and new technology to get across key messages about the importance of testing for HIV and condom use.
A Department of Health spokesperson says: “We’re also addressing it through motivational interviewing programmes in London, Manchester, Leeds and Leicester, which offer testing at community-based events.”
Dr Brady, who is also medical director at the Terrence Higgins Trust, says: “The biggest single cause of death from HIV is late diagnosis. The solution lies in normalising testing for HIV. This would not only save lives it would save the NHS money.
“Because of advances in treatment, people have perhaps grown complacent. They need to be reminded that those who miss out on early diagnosis are still getting sick and dying. We have to raise awareness among GPs and hospital doctors because people with symptoms are passing through surgeries and A & E departments, but aren’t being tested and are going away undiagnosed. “Everyone registered with a GP in areas where HIV is more common should be routinely tested for HIV in the same way that women are offered cervical smears.
“Worryingly, we’re seeing an increase in the number of newlyinfected people in their 50s. Perhaps they’ve come out of a long-term relationship and aren’t accustomed to using condoms. The internet makes it easy for them to find new sexual partners without realising they’re putting themselves at risk. We must get the message across to this older age group that HIV isn’t something that just affects young gay men and the black African population.”
The biggest single cause of death from HIV is late diagnosis
To be effective, the treatment known as post-exposure prophylaxis (PEP) needs to start within 72 hours of exposure to HIV to prevent the virus from becoming established. Treatment consists of a month’s course of antiretroviral drugs.
“If given within the 72-hour window, PEP can reduce risk of infection by 75 to 80 per cent,” says Dr Michael Brady, HIV consultant at London’s King’s College Hospital and medical director at the Terrence Higgins Trust. “This treatment needs as much publicity as possible so that anyone who has had unsafe sex, been raped or sexually assaulted can get it.”
It is now possible to take a combination of drugs in a single tablet, once or twice a day
Recent studies have shown there is also a preventative treatment available that can be taken before sex with someone who is HIVpositive. Known as pre-exposure prophylaxis (PrEP) it is taken 12 to 24 hours before sex and can be given to the HIV-negative partner to help prevent infection. Its development could go some way to help protect the health of women who live in cultures where their HIV-positive partners refuse to wear a condom.
Advances in treatment mean HIV has evolved into a long-term manageable condition allowing people to live with, but not die from, being HIV-positive. Today, if someone infected with the HIV virus is diagnosed early and treated before the level of their CD4 cells – a type of white blood cell that helps the body fight infection – falls below 350, their life expectancy will be around the same as someone who is HIV- negative. Aids develops when CD4 levels fall below 200 and the body’s immune system becomes overwhelmed.
The breakthrough in HIV management came in the late-1990s when scientists realised that by combining at least three antiretroviral drugs, known as triple therapy, they had a much greater chance of keeping the virus under control. Patients are given a combination of two NRTIs (nucleotide reverse transcriptase inhibitors) plus either a NNRTI (non-nucleotide reverse transciptase inhibitor) or a protease inhibitor. It is now possible to take a combination of drugs in a single tablet, once or twice a day.
The regime is called highly active antiretroviral therapy. Prior to its development, patients had to take lots of tablets several times a day and put up with distressing side effects. Dr Brady says: “The old regime was very complicated. Some tablets had to be taken with lots of water, others with food or after food.
“HIV positive patients have to take medication every single day for the rest of their lives so advances have made adherence much easier for them. Most find side effects, such as nausea, diarrhoea and tiredness, settle down after a couple of weeks. Fewer than 5 per cent have ongoing side effects but, now we have more drug combinations to choose from, we can change their medication.”
While the annual global rate of new infections has declined and treatment with antiretroviral medicines worldwide rose from 12 per cent in 2003 to 54 per cent in 2009, nine million in need of treatment are still not receiving it. They live in some of the least developed countries of the world in sub-Saharan Africa and Asia.
To help meet the needs of people with HIV in poorer countries and to advance treatment, two pharmaceutical giants, GlaxoSmithKline and Pfizer, combined resources two years ago to set up ViiV Healthcare. Through its Positive Action for Children Fund, ViiV Healthcare recently gave £3.9 million towards programmes to help prevent mother-to-child HIV transmission in eight countries, including Ethiopia, Uganda and the Cameroon. It also operates a not-for-profit pricing policy for its HIV drugs in 69 low-income countries and has a flexible policy for middle-income nations.