NEWS FROM THE IAS CONFERENCE ON HIV SCIENCE – PARIS FRANCE – JULY 23 -26

Achieving the 90-90-90 target

Michel Sidibé at IAS 2017. Photo by Marcus Rose/IAS.

The 9th International AIDS Society Conference on HIV Science (IAS 2017) opened in Paris with the excellent news that the world is on track to meet the 90-90-90 targets for HIV treatment, by 2020. More than half of people living with HIV now have access to antiretroviral therapy (ART), and AIDS-related deaths have fallen by half since 2005.

UNAIDS set the 90-90-90 target in 2014. It calls on countries to achieve the following goals:

  • 90% of people living with HIV diagnosed by 2020.
  • 90% of diagnosed people on ART by 2020.
  • 90% of people on ART with an undetectable viral load by 2020.

If all these targets are met, AIDS-related deaths will be cut dramatically and the rate of new HIV infections will fall.

The conference heard that progress was now past a tipping point.

In 2016, 70% of people living with HIV knew their status, 77% of people with a diagnosis were accessing treatment and 82% of people taking ART had achieved viral suppression.

Many countries – the UK included – had already met or were close to achieving the 90-90-90 targets.

Excellent progress was also being made in the regions hardest hit by HIV.

Achievement of the targets is already having a meaningful impact on AIDS-related mortality.

In Eastern and Southern Africa, AIDS-related deaths have fallen by almost two-thirds since 2004. The number of new infections is also falling.

The conference heard that the countries with the greatest level of political commitment and leadership had made the most progress towards the 90-90-90 targets. But much more still needs to be done in Eastern Europe and Central Asia, where treatment figures are much lower, with 63% of people living with HIV knowing their status, and only 43% of these accessing ART, although 77% of people on therapy have an undetectable viral load.

In Western and Central Africa, just over 40% of people living with HIV were diagnosed but 83% of these were on treatment, with approximately three-quarters achieving viral suppression.

Community health systems and community health workers were credited with being key to the achievement of the targets.

Rate of new HIV infections halves in Swaziland

Velephi Okello at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

Research from Swaziland provides convincing evidence that increasing the proportion of people living with HIV who have a fully suppressed viral load leads to a fall in the number of new HIV infections.

The conference heard that, since 2011, the number of new HIV infections in the country has halved – during the same period, the proportion of people with a fully suppressed viral load has doubled.

Although the effect of HIV treatment on stopping HIV transmission is well established at the individual or couple level, the impact of wider uptake of treatment on HIV transmission at the population level is less well understood. Research conducted in South Africa has already shown that increasing treatment coverage is accompanied by a reduction in HIV incidence.

This latest study demonstrates – in ‘real world’, population-based research – that increasing the number of people on antiretroviral therapy who have an undetectable viral load has a major impact on HIV transmissions.

A national door-to-door survey conducted in 2011 found that 24% of men and 39% of women were living with HIV, and found that 1.8% of men and 3.16% of women had acquired HIV within the previous 120 days. At the time of the survey, 35% of people living with HIV had an undetectable viral load.

The research was repeated in 2016-17.

HIV prevalence was unchanged on the earlier survey. However, there was a significant reduction in the rate of new infections – falling by 53% in men and 38% in women. Overall incidence was down by 44%.

At the same time, the proportion of people living with HIV who had an undetectable viral load doubled, from 35 to 71%.

The take-home message is that treatment as prevention works. The study “shows that our efforts can pay off and is a proof of concept”, said Professor Linda Gail-Bekker, President of the International AIDS Society.

New WHO guidelines for people with late HIV diagnosis

The World Health Organization (WHO) has issued a new set of guidelines for the treatment and care of people with advanced HIV – including people with a CD4 cell count below 200 or serious HIV-related illnesses and symptoms (WHO stages 3 and 4).

People who are diagnosed with HIV when their CD4 is very low have a very high risk of further disease progression and death and are in urgent need of HIV treatment. For people who are diagnosed with HIV and opportunistic infections such as tuberculosis (TB), the risk remains high even when antiretroviral therapy is started immediately. Although the proportion of people diagnosed late has fallen in recent years, the number still remains unacceptably high.

The new guidelines cover diagnosis, prevention and treatment of serious infections associated with advanced HIV.

Diagnosis

  • CD4 cell count testing – this can identify people at risk of serious infections and disease progression.
  • TB screening – TB is a major cause of death among people diagnosed with HIV late.
  • Cryptococcal antigen testing for people with a CD4 cell count below 100.

Preventive treatments

  • Preventing TB – isoniazid preventive therapy for everyone who doesn’t have active TB.
  • Preventing cryptococcal disease – fluconazole preventive therapy for everyone with a CD4 count below 100 and a positive cryptococcal antigen result.
  • Preventing bacterial infections, toxoplasmosis and malaria – cotrimoxazole prophylaxis for everyone with HIV-related illness; a CD4 cell count below 350; and those living in malarial zones.

HIV treatment

Start HIV therapy immediately, unless a) symptoms suggest TB or cryptococcal meningitis; b) if taking TB therapy, those with a CD4 count below 50 should start antiretroviral therapy within two weeks of starting TB treatment, people with higher CD4 cell counts should start antiretroviral therapy within eight weeks.

Sexual health and PrEP

Sheena McCormack presenting at IAS 2017. Photo by Matthew Hodson, aidsmap.com

The regular screening for HIV and other sexually transmitted infections (STIs) that people using PrEP (pre-exposure prophylaxis) access could be the reason for a surprise fall in new gonorrhoea cases among gay men in London.

Investigators from 56 Dean Street, the largest sexual health clinic in the UK, told the conference that new gonorrhoea cases among gay men attending the clinic fell by a quarter last year.

The precise reason for the fall is unclear, but Professor Sheena McCormack suggested that it could be because people using PrEP have regular sexual health screening, therefore picking up asymptomatic infections and breaking the transmission chain.

The conference also heard more good news about the effectiveness of PrEP, with data presented by investigators from the Australian PrEP demonstration study. The study now involves five states and 5500 individuals have enrolled in the study.

STI rates have remained stable, but new HIV diagnoses have already fallen by 29% and there has been a 43% fall in the number of people diagnosed with very early HIV infection.

Long-acting HIV treatment

Joseph Eron at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

Modern antiretroviral drugs are highly effective if taken as prescribed. However, taking treatment every day can be challenging and long-acting injectable drug formulations could offer an alternative.

The conference heard the latest results from a trial of long-acting HIV treatment.

In the trial, two long-acting injectable antiretrovirals, cabotegravir and rilpivirine, are administered once every 4 or 8 weeks. The research shows that around 90% of people who already had an undetectable viral load when they started treatment in the trial maintained viral suppression over two years.

The study is testing nano-suspension formulations of the two drugs, given as intramuscular injections in the buttocks. Injections currently must be administered by a health care provider, though self-administration is potentially possible in the future, presenter Dr Eron told the conference.

Almost all participants reported injection-site reactions, but these were usually mild or moderate and transient, lasting an average of three days. Only two people (less than 1%) stopped treatment early for this reason. Despite the frequency of injection-site reactions, participants reported that they were highly satisfied with the long-acting therapy and would like to continue it.

Scientific analysis from Clinical Care Options

Clinical Care Options (CCO) is the official online provider of scientific analysis for delegates and journalists.

Over the next few weeks, their coverage will include capsule summaries of important clinical data, downloadable slidesets and expert webinars.

CCO and IAS present live CME/CE-certified webinars

Immediately at the end of the conference, leading experts will explore how the most recent data presented at IAS 2017 may affect your patient care strategies and will answer your questions.

  • Kathleen E Squires, MD: Wednesday 26 July, 9am Pacific, 12pm Eastern, 5pm UK, 6pm Central European
  • Anton L Pozniak, MD, FRCP: Thursday 27 July, 9am Pacific, 12pm Eastern, 5pm UK, 6pm Central European

Click here to register in advance (it’s free!) and submit your own questions.

Download our news app to keep up to date

As well as accessing news from IAS 2017 through our website, you can also download our free app for iPhone or Android.

The apps link to our daily news reports on new research presented at IAS 2017, and other news on HIV treatment and prevention. We also cover key developments in hepatitis, TB and other health conditions linked to HIV.

As well as articles by our own editors, the apps include a daily hand-picked selection of HIV-related stories from other websites around the world.

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