HIV

Dr Laura Waters from Mortimer Market Centre: 2-drug treatment looks good

The International AIDS Society is the largest organisation for HIV professionals in the world and its 10th conference was held in Mexico City. I’ve been lucky to attend a few of these conferences in my time and this was by far the most exciting. There were some really important trial results that will change how we manage HIV.

One of the main highlights of the conference was around 2-drug therapy for HIV. Traditionally we use a combination of 3-drugs to treat most people with HIV – this is because the virus can mutate to become resistant to medication and using 3 drugs makes it much more difficult for the virus.

However, as HIV treatments have improved, and individual drugs are more powerful than earlier options, there’s been a lot of interest in using just 2-drugs instead of 3. 

Potential advantages include fewer side effects, particularly in the long term. Last year results were presented  from a trial called GEMINI for a 2-drug combination of dolutegravir + lamivudine: people starting treatment for the first time did just as well on 2-drugs as they did on a traditional 3-drug combination. 

Although the results were excellent, the study has only been running for a year, which for most prescribers, and for treatment guidelines, wasn’t quite enough evidence to embrace this big change. However, at this conference we saw results out to 2 years for GEMINI and 2-drugs were still as good as 3 with most people having an undetectable viral load. There was also a trial called TANGO showing the same 2-drug combination was just as good for people who already had an undetectable viral load on a 3-drug combination. Importantly nobody whose viral load became detectable on treatment developed any drug resistance. Drug resistance limits the options for future treatment and is best avoided. 

What next? Some international guidelines have already been updated to include this combination and the British HIV Association is considering this question right now. If you are living with HIV you can chat to your clinic about whether this combination is right for you; it may not be if you have, or are not immune to, hepatitis B, or have resistance. At the moment it means taking 2 pills – there is a 2 in 1 pill called Dovato available but we’re waiting to see whether NHS England will let us use it. It should be available in Scotland and Wales very soon.

Other HIV treatment highlights in a nutshell:

◊ There was a French study looking at continuing HIV treatment every day vs. taking it for 4 days then stopping for 3 (“4 days on, 2 days off”). To be fair it worked for most people but for the small number whose viral load went up, there was more drug resistance if they were in the stop/start group. I would not recommend this strategy and please talk to you clinic if you are considering this – some HIV drugs disappear from the body very quickly.

◊ There’s been a lot of debate about HIV treatment and weight gain – the main culprits appear to be a group  of drugs called integrase inhibitors (particularly dolutegravir and a drug just available in England called bictegravir) and the ‘new’ version of tenofovir called tenofovir-AF or TAF. Studies at this conference confirmed the signal, especially for black African women, and there’ll be lots more on this over the next few years. If you think you’ve gained weight on your treatment speak to your clinic – please don’t stop or reduce your medication for
this reason! It may be that these drugs are affecting appetite or metabolic rate and taking extra care about what you eat and increasing your exercise may prevent weight gain.

◊  Starting HIV treatment very early may be beneficial in terms of protecting the immune system and maximising the chance of cure treatments working in the future. It’s important to recognise the symptoms of very early HIV infection and get tested regularly – many clinics will offer HIV treatment within a few days of a confirmed new HIV diagnosis, or even on the same day. You can read about early symptoms (also called “seroconversion”) here:  tht.org.uk/hiv-and-sexual-health/about-hiv/symptoms-hiv 

Moving onto HIV prevention, there was some promising data for a pre-exposure prophylaxis (PrEP) implant. There was also some data on tablet-based PrEP. DISCOVER is a big PrEP trial that presented results earlier this year showing Descovy (a 2-in-1 pill containing ‘new tenofovir’) was just as good at preventing HIV as Truvada (a 2 in 1 pill containing ‘old’ tenofovir). 

A more detailed analysis showed people may reach protective drug levels sooner with Descovy but since both drugs are very effective that’s probably not very important. We know that Descovy affects kidney and bone tests less than Truvada but for most people on PrEP this is not important (and the effects of Truvada on kidneys and bones are less in people without HIV who take it for prevention than for people with HIV who take it for treatment). Descovy is not available for PrEP in the UK but if you have been advised Truvada is not suitable for you but Descovy is, and you can afford it, you can buy Descovy online for around £26 a month: visit Green Cross pharmacy on iwantprepnow.com and click the ‘HIV treatment’ tab for a drug called Taficita.

The Boyz Doc is Dr Laura Waters, an HIV and sexual health consultant at the Mortimer Market Centre in central London. Dr Laura answers your questions every month in Boyz. If you have a question for Dr Laura please email her at boyzdoc@boyz.co.uk

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