A Way Forward
Treatment for HIV
Dr Barry Peters FRCP, DFFP, MD
Dr Ranjababu (Babu) Kulasegaram FRCP
Dr Barry Peters is a consultant physician
specialising in HIV. He completed his
training at St Mary’s Hospital London, has
20 years’ specialist experience managing
HIV, and co-writes the British Treatment
Dr Ranjababu Kulasegaram is a
consultant physician in HIV/GU Medicine
with over 12 years’ experience in
managing HIV, with a special interest
in managing treatment failure, HIV/
Haemophilia and HIV/Hepatitis.
There are over 40 million people globally
infected with HIV and there is no cure.
However, the introduction of new drug
treatments (known as HAART – Highly
Active Antiretroviral Therapy) has
given many patients new hope for a
Diagnosis of HIV Infection
The standard laboratory diagnosis of
HIV infection is straightforward – a simple
and reliable blood test. Newer tests use
mouth swabs or urine as an alternative.
The Haematology Service has
recently been reinforced by the
addition of Dr Mihály Saáry to
the team.There is now a rapid
response service to meet the
needs of patients seeking
specialist advice. New patients
for haematology referrals can
usually be seen within 48 hours.
The service encompasses a wide
range of areas, some of which
are described below.
Anaemias, Polycythaemia, white cell
and platelet problems, bleeding and
bruising problems, thrombotic tendency
etc. Following the consultation, samples
are taken as appropriate and analysed
in the Hospital’s laboratory.
This ensures that the Haematologist
reports on the blood films himself.
The key, however, is to consider HIV in the
first place.Too many diagnoses are missed
because the symptoms that the person
needs a test have not been acted upon.
When to treat with anti-HIV drugs
The updated 2008 British HIV Guidelines
count falls below 350 cells mm
earlier if viral load is high, or there are
HIV symptoms. Special circumstances for
treatment, such as pregnancy, HIV/Hepatitis
co-infection or post-exposure prophylaxis,
are independent of CD4 count.
When one of us (Barry Peters) first
treated HIV in 1988, there was only
one drug in use – AZT – and it was
ineffective by itself.The average survival
from diagnosis with AIDS was 2 years.
Now there are over 20 drugs available,
and the correct combination can offer
many patients with HIV a near-normal life
However, there is a constant danger of the
development of viral drug resistance and
In some instances, a bone marrow aspirate
and trephine biopsy is necessary and
Dr Saáry has specialist expertise and
interest in this.The care of patients with
haematological malignancies is shared with
the Haematologists and Oncologists from
Guy’s and St Thomas’ Hospitals.
The Anticoagulant Clinic is well-established
and has a high reputation for reliability.After
consultation or discharge, some patients
may prefer to use their local laboratories
or clinics for their INR tests. In such cases,
they are offered anticoagulant monitoring
and dosage advice by Dr Saáry.This covers
Haemochromatosis is a particularly
important disease, which, unless diagnosed
early, can lead to tissue damage.The best
treatment failure, conflict
with the other drugs the
patients are taking, and serious
side effects of the drugs.
Avoiding problems with
HIV drugs: The need to
To avoid the problems
highlighted above, patients
need to have their CD4
counts and viral loads
measured at intervals, and
drug resistance, serum drug
levels and genetic tests for appropriate
drug selection when needed. Potential
side effects must be carefully monitored.
Why do patients still get sick?
Patients still get sick with HIV, usually
because of late presentation or poor
adherence to their medicines.Whether
this is the classical PCP pneumonia
or one of the many other conditions
defining AIDS, it is key to diagnose
and treat promptly.
form of early detection in the general
population is routine screening. Most
profiles include (or should include) a
serum iron andTIBC, and the calculated
saturation of Transferrin. If the saturation
is >60% in males or >55% in females, a
serum Ferritin should be done, which not
only confirms the diagnosis but indicates
the stage of the disease. It should be
borne in mind that Ferritin is an acute
phase reactant and Haemochromatosis
should only be diagnosed once other
systemic diseases have been ruled out.
The importance of paying attention to
raisedTransferrin saturations cannot be
over-emphasised and it is likely that many
patients are missed.
Genetic studies are not normally required
to establish the diagnosis, but can be
useful in identifying susceptible family
members, who can thus be earmarked for
Introduced at London Bridge Hospital
drugs/classes of drugs