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A Way Forward

8

Treatment for HIV

in 2008

New Haematology

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

Guidelines.

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.

Introduction

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

normal life.

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.

General Haematology

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

recommends treating

before

the CD4

count falls below 350 cells mm

3

, or

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.

Available treatments

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

expectancy.

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.

TheAnticoagulant Clinic

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

trips abroad.

Haemochromatosis

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

monitor

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

monitoring.

Introduced at London Bridge Hospital

HAART:

drugs/classes of drugs