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Move Delete Spam More aidsmap news: News from the 9th IAS Conference on HIV Science (IAS 2017

News from IAS 2017

International study of gay couples reports no transmissions from an HIV-positive partner on treatment

A study of 343 gay couples, where one partner had HIV and the other did not, has not found a single case of HIV transmission in 16,889 acts of condomless anal sex, the 9th International AIDS Society Conference on HIV Science (IAS 2017) in Paris, France, was told.

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Why curing HIV may be like curing cancer – and may be as difficult

For the last few years, a specialist symposium on HIV cure research has preceded the IAS Conferences and this one was no exception, with a 1.5-day forum at Paris’s Curie Institute on the weekend the conference opened.

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What marks out HIV controllers from others?

What if we are asking the wrong, question, though? What if trying to destroy or at least expose and inactivate every cell containing HIV is not the way forward and instead the answer is to teach the body to simply either ignore HIV, or develop an immune response that controls it? One of the most widely-reported stories of the conference was the discovery of a South African child who had been born and started treatment early but who had now been off antiretroviral therapy (ART) for 8.5 years without development of a viral load.

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Can we achieve a complete HIV cure in more patients?

What all the different approaches discussed in the previous report have in common is to put HIV infection into persistent remission, but they do not completely remove HIV from the body. But in what is still the one case of a person cured of HIV, that is what was achieved; researchers have not managed to find any trace of HIV in the body of Timothy Ray Brown (who attended a symposium presenting the main data from the Cure and Cancer Forum) nearly a decade after he was cured.

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VRC01 antibody can delay but not prevent viral rebound after interruption of early treatment

A broadly neutralising antibody modestly delayed the resurgence of viral replication following interruption of antiretroviral therapy (ART) started during very early infection, but all study participants ultimately experienced viral rebound, according to results presented at the conference.

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Long-acting NRTI shows promise for HIV treatment and PrEP

A single oral dose of MK-8591, a long-acting antiretroviral in a novel drug class, suppressed HIV for seven days in an early clinical trial, and the drug also appears to protect monkeys from rectal infection with an HIV-like virus, researchers reported at the conference.

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Stillbirth more frequent in women with HIV in UK and Ireland than in general population

The stillbirth rate among women living with HIV in the UK and Ireland from 2007 to 2015 was more than twice that of the general population, Graziella Favarato, presenting on behalf of the National Study of HIV in Pregnancy and Childhood (NSHPC), told participants at the conference.

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US HIV funding decisions on PEPFAR in 2017 will have critical effect on ability to reach 90-90-90 goals

A withdrawal of United States funding for HIV treatment and prevention in sub-Saharan Africa could lead to 20 million additional HIV infections and 2 million additional AIDS deaths between now and 2032, according to modelling of the impact of US funding carried out by Imperial College, London, and presented at the conference.

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First protease inhibitor combination pill maintains viral suppression

The first once-daily single-tablet regimen containing a protease inhibitor maintained viral suppression in almost everyone who switched after achieving undetectable HIV RNA on a multi-pill regimen, according to a report at the conference.

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Adolescents with HIV do better in more prosperous African countries, even with treatment

Adolescents who acquired HIV perinatally were less likely to die, grew faster and had better immune restoration on treatment if they lived in upper-middle income countries in sub-Saharan Africa, a comparative study presented at the conference reported.

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France’s next PrEP study aims to assess the wider impact of PrEP on the HIV epidemic

France is launching a new study which will enrol 3000 new pre-exposure prophylaxis (PrEP) users over the next three years, Jean-Michel Molina told the conference. Whereas previous studies, including Molina’s own IPERGAY study, proved the benefit of PrEP to the individual taking it, the new study has set an ambitious target in relation to the public health benefit of PrEP. The aim is to show that having an extra 3000 people take PrEP will result in a marked fall in HIV diagnoses among men who have sex with men in the Paris region.

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Dutch study finds out whether gay men prefer daily or on-demand PrEP

In Europe, whether through national programmes or in trials, people are more often than not being given the choice of taking pre-exposure prophylaxis (PrEP) daily or intermittently (“event-driven” or “on-demand” PrEP). The French national rollout programme offers this choice as does the one recently set up by Scotland. The large implementation study hopefully soon to start in England will offer this choice too.

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Long-acting cabotegravir injection shows promise for HIV prevention

A long-acting injectable formulation of cabotegravir given every 8 weeks produces high enough drug levels in both men and women to offer protection against HIV, according to results from the HPTN 077 study presented at the conference. But another injectable prevention candidate, long-acting rilpivirine, has been abandoned.

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Doravirine combination pill looks good for initial HIV treatment

A single-tablet regimen containing the next-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) doravirine reduced HIV viral load as much as an efavirenz-based co-formulation, but it had a more favourable side-effect profile, according to results from the DRIVE-AHEAD study presentation at the conference.

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Acute kidney injury ‘uncommon’ but unpredictable on tenofovir and ritonavir

Doctors need to monitor patients regularly for kidney function if they are taking tenofovir disoproxil, especially if combined with ritonavir, the conference heard.

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Countries and donors should aim for new $90-$90-$90 target on HIV, hepatitis, TB drug prices, study shows

HIV, hepatitis B and C and tuberculosis (TB) can each be treated for less than $90 a year where generic drugs can be made available, Dzintars Gotham of Imperial College, London, reported at the conference.

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Medical male circumcision for HIV has benefits for women too

South African women whose most recent sexual partner was circumcised are less likely to have HIV, suggesting that the voluntary medical male circumcision programmes have benefits for women too, according to a study presented to the conference.

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Demonstration projects explore the feasibility of PrEP for adolescents and young women in South Africa

One of the first studies to explore the acceptability, safety and use of pre-exposure prophylaxis (PrEP) in adolescents in an African context has found that PrEP was safe and tolerable, although PrEP usage and adherence did tail off during the 12 months of the programme.

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Ipergay trial: PrEP still protected people who had less sex and used it less often

A substudy of the French Ipergay trial of ‘on-demand’ pre-exposure prophylaxis (PrEP) has found that PrEP was just as effective for participants who had sex less often than average, and so took PrEP less often, as long as they did take it when it was needed.

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Another HIV vaccine efficacy trial will start this year

A year ago, one of the biggest pieces of prevention news at the Durban International AIDS Conference was the announcement that a large HIV vaccine efficacy study would start in South Africa. HVTN 702, now running, is only the eighth human vaccine efficacy trial ever run in the history of the HIV epidemic and the first since 2009.

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Glecaprevir/pibrentasvir is effective for people with HIV/HCV co-infection

AbbVie’s new pangenotypic regimen combining glecaprevir and pibrentasvir cured almost all HIV-positive people with hepatitis C co-infection in the EXPEDITION-2 study, according to a presentation at the conference.

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90-90-90 progress in southern Africa: HIV testing gap needs to be closed in young people and men

Three African countries with high burdens of HIV infection are achieving very high levels of HIV treatment initiation and viral suppression but need to make better progress on HIV testing in order to achieve the 90-90-90 targets, according to results from large studies presented at the conference.

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Can self-testing engage ‘hard-to-reach’ men with HIV testing?

Adding HIV self-testing as an additional option to a door-to-door programme offering HIV testing in Zambia boosted the uptake of HIV testing among men, younger adults and those who had previously refused HIV testing, Helen Ayles of the London School of Hygiene and Tropical Medicine told the conference. It appears that HIV self-testing may have a particular impact on testing rates in men and could contribute to meeting the 90-90-90 targets in men.

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Integrase inhibitors not causing higher rates of adverse birth outcomes, Botswana and French studies show

Dolutegravir-based antiretroviral therapy (ART) started in pregnancy is as safe as efavirenz-based ART, according to a study of birth outcomes at eight maternity wards throughout Botswana accounting for close to half of all nationwide deliveries, Rebecca Zash of Beth Israel Deaconess Medical Center told participants at the conference.

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New guidance says start HIV treatment within 7 days of diagnosis – but is everyone ready?

Everyone diagnosed with HIV should be offered the option to start treatment within seven days of diagnosis and everyone who feels ready should have the option to start treatment on the day of diagnosis, the World Health Organization (WHO) has recommended.

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New integrase inhibitor bictegravir works well for first-line HIV treatment

A single-tablet regimen containing the experimental integrase inhibitor bictegravir was as effective as two widely used approved regimens for first-line therapy in a pair of phase 3 clinical trials, according to presentations at the conference.

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Hepatitis C treatment is effective and feasible in Africa

Treatment for hepatitis C in sub-Saharan Africa can produce cure rates as high as those seen in industrialised countries, with high adherence and minimal side-effects, according to a presentation at the conference.

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High uptake of HIV self-testing by female sex workers in African countries

A year ago there was virtually no evidence on the acceptability and feasibility of HIV self-testing in female sex workers, but a series of presentations from Zimbabwe, Zambia, Uganda and Kenya at the conference suggest that self-testing has potential in improving the uptake of testing among sex workers in Africa.

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South African child has controlled HIV off treatment for 8.5 years

A nine-year-old South African child who was diagnosed with HIV infection at one month of age and received HIV treatment for 40 weeks during infancy has suppressed the virus without anti-HIV drugs for eight and a half years, scientists reported at the conference.

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Programme to provide free self-tests helps gay men to test for HIV more often

Providing free HIV self-testing kits to gay and bisexual men is an effective way to increase the frequency with which men test for HIV and the number of new HIV diagnoses, Robin MacGowan of the US Centers for Disease Control and Prevention (CDC) told the conference.

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Less frequent clinic visits for HIV care: fine tuning needed

Shifts to less frequent clinic visits and medication pick-ups to free up healthcare resources and make life easier for people living with HIV are being implemented successfully in some African countries, but still need fine tuning, several studies presented at the conference show.

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Improved treatment for cryptococcal meningitis in HIV could save thousands of lives – if generic drug becomes available

Urgent action is needed to improve access to the antifungal drug flucytosine, say investigators, following the presentation of the results of a trial showing that treatment containing flucytosine is superior to any other form of treatment in reducing the risk of death from cryptococcal meningitis in people with very advanced HIV disease.

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Swaziland: new infections halved in five years as HIV treatment scales up

New HIV infections have halved in Swaziland since 2011 at the same time as the proportion of people on antiretroviral treatment with fully suppressed viral load has doubled, the conference heard. It is the first direct evidence that expanding HIV treatment results in fewer HIV infections in a country with a major epidemic, researchers said.

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Long-acting cabotegravir + rilpivirine injection shows good results at 96 weeks

Two long-acting injectable antiretrovirals, cabotegravir and rilpivirine, administered once every 4 or 8 weeks maintained viral suppression in about 90% of people who started therapy with an undetectable viral load, according to the latest results from the LATTE-2 trial, presented at the conference.

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London gonorrhoea rates fall, and HIV rates falling in Australia as more join PrEP demo

Gonorrhoea diagnoses among gay men attending the largest STI clinic in the UK at 56 Dean Street in London’s Soho have declined by 24% in the last year, the clinic’s Professor Sheena McCormack, principal investigator of the PROUD PrEP study, told the conference.

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World on track to reach the 90-90-90 targets for HIV treatment by 2020

The world is on track to reach global targets for reducing AIDS deaths and HIV treatment access by 2020, but some regions of the world risk falling further behind due to lack of political commitment, UNAIDS announced in the run-up to the conference.

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WHO recommends package of tests, treatment and prevention for ‘urgent need’ people with HIV with low CD4 counts

A new package of measures to ensure rapid initiation of antiretroviral treatment and diagnosis of opportunistic infections has been recommended by the World Health Organization (WHO) to reduce the still high rates of death in people diagnosed with HIV at a very advanced stage of disease.

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Other recent news headlines

PrEP demand in England is rapidly accelerating – and most will want to join the trial

A survey of people currently using pre-exposure prophylaxis (PrEP) has found that PrEP use has rapidly accelerated in the last year, with more than half of those surveyed starting since the beginning of 2017. The short survey was conducted by PrEP advocacy sites iwantPrEPnow and PrEPster, with assistance from Public Health England.

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Monthly shot could be the ‘next revolution’ in HIV therapy, replacing daily pills


The 9th International AIDS Society conference has drawn thousands of researchers to Paris this week. (Francois Guillot/AFP/Getty Images)

HIV/AIDS is no longer the death sentence it once was, but maintaining the strict regimen required to keep the virus at bay — one or more pills daily — still poses a major challenge to many people who are infected. Adherence is low among some populations, given the effort that is required to obtain, keep and store the medications.

That may soon change. On Monday, scientists reported an important advance in the development of a long-acting antiretroviral shot. According to an international study involving 309 patients, an injection that combines two drugs, cabotegravir and rilpivirine, appears to be as safe and effective at suppressing HIV as the daily oral regimen.

Writing in the Lancet, David Margolis of ViiV Healthcare, called it “the next revolution in HIV therapy.”

In the study, which was conducted at 50 centers in the United States, Germany, Canada, Spain, France and Germany, patients were begun on 20 weeks of daily oral medication. Once that medication had brought their viral loads down, they were given the shots as a “maintenance therapy.” Some were given the shot at four-week intervals and others at eight-week intervals. A control group continued to take the pills.

The majority of the patients tolerated the therapy well, though nearly everyone reported some mild to moderate pain at the injection site. The rates of some adverse events like headaches were similar across all three groups.

At 96 weeks, 84 percent of the patients in the oral medication group were able to keep their viral load suppressed, compared with 87 percent of the four-week shot group and 94 percent of the eight-week shot group.

The shots could revolutionize patient care in places like Africa, where it can be difficult for many people to get to a pharmacy regularly. But Mark A. Boyd, a professor at the University of Adelaide, wrote in a commentary piece accompanying the main article that there are trade-offs with both a pill and injection.

NAM AIDS MAP – 9TH IAS SCIENTIFIC AIDS CONFERENCE – PARIS FRANCE JULY 2017

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Thursday 27 July 2017

Contents

PrEP for adolescents in southern Africa

Katherine Gill presenting at IAS 2017. Photo by Roger Pebody, aidsmap.com

Adolescent girls and young women aged 15 to 24 account for 23% of all new HIV infections in sub-Saharan Africa. Females are much more vulnerable to HIV than their male peers. Whereas 0.7% of adolescent boys aged 15 to 19 have HIV in South Africa, the equivalent figure for girls is 5.6%. In the 20 to 24 age group, 5.1% of men and 17.4% of women have HIV. In some parts of the country, prevalence is even higher.

New prevention options that are acceptable to young people, and especially to young women, are urgently needed in southern Africa. Pre-exposure prophylaxis (PrEP) for young people is being considered in several countries as a potential option.

One of the first studies to explore the acceptability, safety and use of PrEP with adolescents in an African context has found that PrEP was safe and tolerable, although PrEP usage and adherence did tail off during the 12 months of the programme.

Presenting the findings of the PlusPills project to the 9th International AIDS Society Conference on HIV Science (IAS 2017) in Paris this week, Katherine Gill of the Desmond Tutu HIV Foundation said that South African adolescents need access to PrEP with tailored adherence support and more frequent clinic visits. Less frequent dosing schedules, if validated, could be of interest to this population, she suggested.

Yogan Pillay of South Africa’s National Department of Health said that five demonstration studies had already provided preliminary data on how to target and deliver PrEP to adolescent girls and young women.

The uptake of PrEP varies considerably between different studies and in different social contexts, ranging from 36 to 98% of those approached. Retention and adherence also varies considerably, with between 40 and 70% of participants either reporting continued PrEP use or having sufficient levels of the drug in their blood.

The experience so far has underscored the need for flexibility and adaptability in providing oral PrEP to young women in South Africa. The diversity of settings in which young women live means that PrEP cannot be a one-size-fits-all prevention tool.

Concern about side-effects has been a recurrent challenge and a frequent reason for young people to discontinue PrEP. Other reasons for opting out of PrEP include dislike of the pill’s size or taste, and difficulties remembering to take it every day.

Pillay said that community education is critical to uptake and adherence. It needs to try to reduce the stigma of young people’s sexual activity and to legitimise PrEP as a form of prevention. Parents and caregivers are extremely influential in adolescent girls’ decision-making about PrEP.

The South African government is hoping to deliver PrEP through clinics in tertiary and vocational education colleges and universities, as well as in family planning services. Work is needed to ensure that staff are sensitive and do not stigmatise PrEP users, Pillay said.

Injectable PrEP

Raphael Landovitz at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

A long-acting injectable formulation of cabotegravir given every 8 weeks produces high enough drug levels in both men and women to offer protection against HIV, according to results from the HPTN 077 study presented at the conference. But another injectable prevention candidate, long-acting rilpivirine, has been abandoned.

The effectiveness of antiretroviral drugs for HIV pre-exposure prophylaxis (PrEP) is heavily dependent on maintaining good adherence. Some people may find it easier to take PrEP consistently if they could have an injection every month or two, instead of taking pills every day or when they plan to have sex.

The HPTN 077 study is looking at the safety, tolerability and acceptability of long-acting injectable cabotegravir, an experimental integrase inhibitor. As a phase 2a trial, it is not designed to evaluate prevention efficacy. (The conference also heard promising data on long-acting cabotegravir for HIV treatment.)

Cabotegravir is being given every eight weeks as an intramuscular injection. The study found that injections were well tolerated – only one out of 199 participants left the study because of an injection-site reaction.

Although HPTN 077 was not intended to assess prevention efficacy, no participant acquired HIV while receiving regular injections. One participant seroconverted 48 weeks after their last cabotegravir injection, when levels of the drug were undetectable.

A larger study, HPTN 083, comparing the efficacy of injectable cabotegravir compared to oral Truvada (tenofovir/emtricitabine) for PrEP is now underway.

First-line treatments for HIV, viral hepatitis, TB don’t cost more than $90 to make – so why pay more?

Dzintars Gotham presenting at IAS 2017. Image credit: Enzo Poultreniez / http://aides.org

HIV, hepatitis B and C and tuberculosis can each be treated for less than $90 a year where generic drugs can be made available, Dzintars Gotham of Imperial College, London, reported at the conference.

The findings come from an analysis of prices paid for the raw materials used to make drugs for the treatment of each disease, and the costs of manufacturing each product.

The research showed that a year’s supply of the first-line antiretroviral combination of tenofovir, emtricitabine and efavirenz can be manufactured for US$78, and a course of treatment for hepatitis C for between $47 and $79.

Although the cost of antiretroviral treatment has fallen dramatically since generic manufacturers first began to manufacture versions of antiretroviral drugs in India in 2001, generic products have not been available in all countries due to patent restrictions. Over the next few years, it will begin to be possible to provide first-line treatment for HIV using generic drugs, as patents expire on some of the key drugs used in HIV treatment.

To achieve global targets for HIV treatment and viral suppression, hepatitis C elimination and reducing the burden of tuberculosis and drug-resistant tuberculosis, large increases in the number of people treated for each disease will be necessary. Cutting the prices paid for medicines will be essential if countries are to afford large treatment programmes for HIV or viral hepatitis.

Treatment can become more affordable as patents expire and more countries are able to obtain generic versions of drugs to treat HIV and viral hepatitis, the researchers said. Even where patents are still in force, knowing the costs of production should enable governments to demand more affordable prices from pharmaceutical companies, speakers at a symposium on drug pricing agreed.

Male medical circumcision: benefits for women?

Carlos Toledo presenting at IAS 2017. Photo by Roger Pebody, aidsmap.com

It is well established that circumcision protects men against acquiring HIV, but until now there has been little evidence of benefit to women of men being circumcised. Almost a decade ago, a meta-analysis found no evidence to suggest that circumcision of men directly reduced the risk of women acquiring HIV.

However, a study presented to the conference found that South African women whose most recent sexual partner was circumcised are less likely to have HIV, suggesting that the voluntary medical male circumcision programmes do have benefits for women too.

Studies have shown a reduced risk of human papillomavirus, genital ulcers, herpes simplex virus type 2, syphilis, bacterial vaginosis, and T vaginalis in women whose partners are circumcised. This is likely due to changes in the male partner’s anatomy, making transmission of an infection less likely.

However, in the case of HIV, it is more likely that male circumcision can benefit women by reducing the prevalence of HIV in men who have been circumcised.

The new study involved men and women in KwaZulu-Natal, South Africa, and found that women whose most recent partner was circumcised had lower rates of HIV (42%) than women whose partner was not circumcised (54%). Controlling for other factors, an analysis of the results found that women with circumcised partners had a 30% lower likelihood of having HIV. They were also less likely to have herpes simplex virus type 2.

Side-effects of commonly used drugs

Tenofovir disoproxil is one of the most frequently used antiretroviral drugs in the world today. Rare but serious side-effects of the drug have the potential to affect a substantial number of people because of its widespread use.

Doctors need to monitor people regularly for kidney function if they are taking tenofovir, especially if combined with ritonavir, the conference heard this week.

Fanconi syndrome is an acute type of kidney failure caused by substances that would normally be reabsorbed being released out of the blood into the urine instead: phosphates (which help build bone), amino acids and bicarbonate, which raises the acidity of the blood to dangerous levels (acidosis).

Dr Nicholas Medland of Monash University in Melbourne, Australia, told delegates that Fanconi syndrome was “uncommon, but not rare”, with 1.25% (one in 80) of the people in his study developing it within a ten-year period. Importantly, it could appear unexpectedly, in people with no characteristics linked to kidney disease.

Tenofovir has also been linked to bone loss in some studies. However, Dominique Costagliola of the French national medical research agency INSERM told delegates she had found no association between tenofovir, or any other HIV drug, and the risk of bone fractures of the type associated with low bone mineral density.

New option for first-line treatment: doravirine

Kathleen Squires at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

A single-tablet regimen containing the next-generation non-nucleoside reverse transcriptase inhibitor (NNRTI) doravirine, reduced HIV viral load as much as an efavirenz-based co-formulation, but it had a more favourable side-effect profile, according to results from the DRIVE-AHEAD study presented at the conference.

Current first-line antiretroviral therapy regimens are safe and highly effective. Integrase inhibitors have largely replaced NNRTIs for first-time treatment in recent years, but having multiple potent and well-tolerated drugs from different antiretroviral classes offers more options for individualised therapy.

Doravirine, an investigational NNRTI being developed by Merck, has a unique resistance profile and is active against HIV with common NNRTI-resistance mutations including K103N. It can be taken with or without food and has low potential for drug-drug interactions.

The DRIVE-AHEAD study showed that after 48 weeks on treatment, 84% of people in the doravirine arm of the study and 81% in the efavirenz arm had undetectable viral load, showing that the new co-formulation was non-inferior. People who received doravirine were less likely to experience central nervous system side-effects such as dizziness, sleep problems or depression.

Treatment for hepatitis C co-infection: a new pangenotypic option

Karine Lacombe at IAS 2017. Photo by Steve Forrest/Workers’ Photos/IAS

AbbVie’s new pangenotypic regimen combining glecaprevir and pibrentasvir cured hepatitis C virus (HCV) in almost all participants living with HIV and HCV co-infection in the EXPEDITION-2 study, according to a presentation at the conference.

Treatment was highly effective, with 98% having continued undetectable HCV RNA at 12 weeks post-treatment (SVR12).

Glecaprevir/pibrentasvir (Maviret) is expected to be approved by the US Food and Drug Administration in August. It has received a positive opinion from the scientific committee of the European Medicines Agency (the CHMP) and should receive European Union marketing approval within the next few months.

“These results suggest that the glecaprevir/pibrentasvir regimen could be the first 8-week, pangenotypic treatment option for HCV/HIV-1 coinfected patients without cirrhosis,” the researchers concluded.

NAM AIDS MAP – 9TH IAS SCIENTIFIC AIDS CONFERENCE – PARIS FRANCE JULY 2017

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Wednesday 26 July 2017

Contents

HIV vaccine study to start this year

Hanneke Schuitemaker at IAS 2017. Photo by Gus Cairns, aidsmap.com

A major HIV vaccine study will start this autumn, involving 2600 young women in South Africa, Zambia, Zimbabwe, Malawi and Mozambique, the 9th International AIDS Society Conference was told.

The new trial will examine the safety and effectiveness of an experimental vaccine called HVTN 705. It consists of two doses of an adenovirus vector called ad26. Adenoviruses are a common viral family that are mainly known for causing colds, though the vector should not do that. This is then followed by two more doses of the adenovirus and a booster of the gp 140 envelope protein.

Results from preliminary studies suggest that it provokes a strong anti-HIV response.

The conference heard that despite major advances with HIV treatment and care, there is still an urgent need for a vaccine.

Researchers are now optimistic that vaccine development is on the right track. Another large study – examining an experimental vaccine called HVTN 702 – is already up and running.

South African researcher Glenda Gray, said, “I feel we have reached a pivotal moment in HIV vaccine development”.

WHO recommends starting ART within a week of diagnosis with HIV

Presentation by Brendan Maughan-Brown at IAS 2017. www.ias2017.org

The World Health Organization (WHO) has issued new guidance recommending that everyone newly diagnosed with HIV should be offered the chance to start antiretroviral therapy (ART) within a week of their diagnosis. People who feel ready should be able to start treatment on the day of their diagnosis.

The recommendations are based on the results of a study that showed that people who started ART on the day of their diagnosis were more likely to be retained in care and have a suppressed viral load 12 months later.

But research presented to the conference this week showed the importance of adequately preparing people to start therapy very soon after diagnosis. Indeed, a study in Uganda actually showed that people who started ART on the day of their diagnosis were considerably more likely to drop out of HIV care compared to people who started treatment days or weeks after diagnosis.

“‘Steep’ ART initiation should be backed up by intensive pre-ART counselling,” said one of the investigators.

Separate research conducted in Cape Town showed that knowledge of ART was associated with readiness to start treatment. Patients were also better prepared to start treatment if they knew someone whose health had improved thanks to ART. The investigators also noted that preparing people for rapid treatment initiation involved overcoming concerns about possible side-effects among people who were in good health.

PrEP still effective with intermittent use

Guillemette Antoni at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

Analysis of results from a major pre-exposure prophylaxis (PrEP) study has shown that the therapy was still protective against infection with HIV when taken intermittently.

Results from the Ipergay study had already shown that gay and other men who have sex with men were significantly less likely to acquire HIV if they used PrEP.

The study was designed to look at ‘on demand’ use of PrEP – intermittent use of the drug in anticipation of sexual activity. The treatment regimen involved taking a double dose of PrEP in the 24 hours before sex involving a risk of HIV was anticipated, followed by a single dose on each of the following two days.

But many of the study participants were taking PrEP so often they were effectively on continuous therapy.

Researchers therefore looked at the risk of infection for men who did take the drug intermittently. None of the men using PrEP in this way acquired HIV, and close statistical analysis suggested that use in this way was just as effective as taking PrEP continuously.

“Although the number of person-hours in this substudy was small, we hope it will add to the evidence that on-demand PrEP is effective,” commented one of the researchers.

Reaching the 90-90-90 target: testing gap in young people and men

Staff conducting the population HIV impact assessment (PHIA). Image credit: http://phia.icap.columbia.edu

Malawi, Zambia and Zimbabwe have high rates of antiretroviral therapy (ART) coverage and viral suppression, but need to boost rates of HIV testing to meet the 90-90-90 target.

Research in all three countries, presented to the conference, showed that young people were more likely to be unaware of their HIV status, and that men were more likely than women to be unaware of their HIV status.

A study conducted in Zambia in 2016 showed that of people who knew they were living with HIV, 85% were on ART, and of these, 89% had an undetectable viral load. However, only two-thirds of the Zambian population are aware of their HIV status, with awareness higher among women than men (68 vs 62%).

The situation in Zimbabwe was broadly similar. A survey in 2015-16 showed that 73% of people were aware of their HIV status, 87% of these were on treatment and 87% of people on treatment had an undetectable viral load. Individuals aged under 35 were much more likely to be unaware of their HIV status than older people, and men were almost twice as likely as women to be unaware if they were living with HIV.

Finally, a survey of women in Malawi in 2016 showed that 76% were aware of their HIV status. However, awareness differed according to age, from a high of 80% in the over-35s to just 42% of 16 to 19 year olds. This pattern was repeated in terms of treatment uptake and viral suppression.

Integrase inhibitors safe to use during pregnancy

Rebecca Zash at IAS 2017. Photo by Steve Forrest/Workers’ Photos/IAS

Two separate studies point to the safety of integrase inhibitor-containing antiretroviral therapy (ART) during pregnancy.

Integrase inhibitors are widely used in first-line ART. The studies presented at the conference are the first large studies to examine the safety of raltegravir and dolutegravir during pregnancy.

Research conducted in Botswana showed similar rates of any adverse birth outcomes for dolutegravir vs efavirenz-based combinations. Rates of pre-term births were comparable for the two drugs, as was the risk of giving birth to an infant small for its gestational age.

Separate French research examined the safety of raltegravir during pregnancy. It involved 479 infants exposed to raltegravir during pregnancy between 2009 and 2015 and found no evidence of an association between birth defects and exposure to raltegravir.

Stillbirths and late miscarriage were rare (1 and 0.4%, respectively). Pre-term births accounted for 14% of deliveries. There were two cases of perinatal HIV infection.

Self-testing

Helen Ayles presenting at IAS 2017. Photo by Roger Pebody, aidsmap.com

Self-testing may be a good way of ensuring that ‘hard-to-reach’ men test for HIV, according to research conducted in Zambia.

The study showed that adding self-testing as an option, in a door-to-door HIV testing programme, boosted testing rates among some traditionally harder-to-reach groups, including men, younger adults and individuals who had previously refused to test.

Self-testing was popular among individuals who were concerned about clinic waiting times and stigma. There were also perceived advantages relating to confidentiality, control and convenience.

Investigators were hopeful that self-testing is a solution for engaging ‘hard-to-reach’ groups such as working men and mobile populations with HIV testing.

Other research examined the secondary distribution of self-testing kits and its impact on testing, for instance women passing on kits to their male partners, or the distribution of kits between friends.

Changing the model of HIV care: reducing the frequency of clinic visits

MSF Community Adherence Club KwaZulu-Natal. Photo by Greg Lomas / Scholars and Gentlemen / Médecins sans Frontières

Less frequent clinic visits can be more convenient for people accessing HIV care and free up healthcare workers’ time, according to research presented at the conference.

The studies looked at multi-month prescribing of antiretroviral therapy (ART), with patients given several months of medication in one go rather than a monthly prescription refill. But the research also showed that reducing the frequency of medication pick-ups wasn’t suitable for all patients, and that fine-tuning was needed for the service to work smoothly.

In Malawi, patients were eligible for multi-month prescribing if they’d been on ART for at least six months, had a viral load below 1000 copies/ml and had good adherence. But a survey of healthcare facilities showed that 40% of patients who were ineligible were also receiving several months of medication. Over 75% of ineligible patients who moved to the multi-month model had a viral load over 1000 copies/ml and 39% had not been on ART for long enough to be eligible. Lack of knowledge of systems was the main reason why ineligible patients were receiving this type of care or for eligible patients not being shifted to multi-month prescribing.

Other research explored multi-month prescribing in younger patients. Data were presented on 15,000 children and young people in six African countries. Patients who shifted to the multi-month model attended their clinic every 60 days, compared to every 39 days with the previous standard of care. Outcomes were good among those shifted to multi-month prescribing.

Another way of reducing clinic visits is medication pick-up from community adherence clubs. However, patients who continued to attend their clinic to pick up ART were more likely to be retained in care and virally suppressed than those using adherence clubs to obtain their medication.

NAM AIDS MAP – 9TH IAS CONFERENCE 2017 PARIS FRANCE

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Tuesday 25 July 2017

Contents

International study of gay couples reports no transmissions from an HIV-positive partner on treatment

Image from Opposites Attract study: www.oppositesattract.net.au

A study of 343 gay couples, where one partner had HIV and the other did not, has not found a single case of HIV transmission in 16,889 acts of condomless anal sex, the 9th International AIDS Society Conference on HIV Science (IAS 2017) was told today.

The Opposites Attract study looked at whether HIV is transmitted between gay male couples of different HIV status when the HIV-positive partner is on treatment that fully suppresses HIV. The HIV-positive partners in Opposites Attract had an undetectable viral load 98% of the time.

The study recruited and followed-up gay couples at clinics in Australia, in Bangkok and in Rio de Janeiro.

The evidence from Opposites Attract adds to the evidence from the PARTNER study that people living with HIV who are on effective HIV treatment that fully suppresses their virus cannot pass on HIV through sex. Taken together, the two studies have not found a single case of HIV transmission in nearly 40,000 acts of condomless anal sex between gay men.

This adds further strength to the “U=U” (Undetectable equals Untransmittable) tagline of the Prevention Access Campaign, whose consensus statement has been signed by NAM and also by the International AIDS Society (IAS), organisers of this week’s Conference on HIV Science in Paris.

At a press conference on Monday about viral load and infectiousness, Dr Anthony Fauci, director of the US National Institute for Allergies and Infectious Diseases, said: “Scientists never like to use the word ‘Never’ of a possible risk.

“But I think in this case we can say that the risk of transmission from an HIV-positive person who takes treatment and has an undetectable viral load may be so low as to be unmeasurable, and that’s equivalent to saying they are uninfectious. It’s an unusual situation when the overwhelming evidence base in science allows us to be confident that what we are saying is fact.”

Child has controlled HIV despite being off therapy for 8.5 years

A nine-year-old in South Africa has well-controlled viral load despite being off HIV treatment for 8.5 years, the conference was told.

The child was a participant in the CHER study, which compared two treatment strategies for HIV-positive infants. Diagnosed with HIV when one-month old, the child started antiretroviral therapy (ART) one month later and was randomised to a group that received 40 weeks of ART.

Now aged 9.5 years, the child has maintained an undetectable viral load since stopping treatment; the number of cells containing HIV DNA – the viral reservoir – has also remained stable since treatment was stopped.

The child is able to mount an immune response to HIV. It’s possible that HIV may be present at extremely low levels, but no virus capable of replication has been detected using various testing techniques.

Researchers have been careful not to describe the child as cured and are still unclear why the viral load has remained undetectable for such a long period without therapy.

The child is the third example of an infant who began HIV treatment very soon after birth, stopped treatment after months or years and went on to control HIV infection for a prolonged period. One of these children maintains viral control eleven years after stopping treatment.

Experimental integrase inhibitor bictegravir does well in clinical trial

Joel Gallant presents new data on bictegravir at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

A single-tablet combination containing the experimental integrase inhibitor bictegravir was as effective as two established HIV treatment combinations, according to studies presented at the conference. The studies involved people starting antiretroviral therapy for the first time.

The first study compared bictegravir to dolutegravir, both taken with emtricitabine/tenofovir alafenamide (TAF). The results of this phase 3 study updated data from previously presented phase 2 research.

At week 48, the bictegravir combination was shown to be non-inferior to the dolutegravir-containing regimen, with 89 and 93% of participants, respectively, having an undetectable viral load. Treatment discontinuations were slightly more common with bictegravir (3 vs 1%), but these were usually for reasons other than poor efficacy or tolerability. Virological failure was rare. Headache and diarrhoea were the most commonly reported side-effects.

A second study compared the same bictegravir combination to the Triumeq combination pill containing dolutegravir, abacavir and lamivudine.

At week 48, rates of viral suppression were comparable for the two combinations (92 vs 93%), demonstrating the non-inferiority of the experimental drug. Virological failure was rare with both regimens.

Several side-effect-related outcomes favoured the bictegravir combination.

Studies looking at the safety and efficacy of bictegravir in people switching treatment are fully enrolled; a study involving women will report in 2018 and research involving children and adolescents is underway.

Hepatitis C treatment feasible and effective in Africa

Karine Lacombe of Saint-Antoine Hospital, Paris, at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

Treatment for hepatitis C virus (HCV) in Africa using direct-acting antivirals (DAAs) can produce cure rates as good as those seen in industrialised countries, data presented to the conference show.

The researchers believe these findings support the scale-up of HCV testing and treatment access in resource-limited settings.

Primary analysis of a study conducted in Cameroon and Ivory Coast were presented to delegates. The findings were highly encouraging.

People with genotypes 1 and 4 were treated with sofosbuvir/ledipasvir (Harvoni) for 12 weeks, while those with genotype 2 received sofosbuvir plus weight-based ribavirin.

A sustained virological response was observed in 89% of participants overall, with 78% of people with cirrhosis also attaining this outcome.

These cure rates compare to those observed in Europe and North America.

However, cost will be a major barrier to rolling out access to DAAs in resource-limited settings and advocacy is needed to ensure the availability of generic formulations. The assistance of international funders will also be needed.

Self-testing for HIV: gay men

Robin MacGowan at IAS 2017. Photo by Roger Pebody, aidsmap.com

Providing free self-testing kits increases the frequency with which gay men test for HIV and also increases HIV diagnosis rates, according to research presented to the conference.

Research conducted in the US enrolled over 2000 HIV-negative gay men and other men who have sex with men. They were randomised into intervention and control arms: men in the intervention arm received four self-testing kits through the post to be used over a 12-month period, whereas men in the control group didn’t receive anything.

Every three months, participants completed questionnaires asking about their HIV testing behaviour.

Men who received the free self-testing kits tested for HIV more frequently: 79% reported at least three tests during the study period, compared to 22% in the control group.

A total of 22 men in the intervention group were diagnosed with HIV, double the number seen in the control arm. Although men in the later group were more likely to be linked to HIV care than men given free self-tests, the difference was not statistically significant.

A pilot study conducted by the Terrence Higgins Trust, a UK-based HIV charity, showed that the distribution of free self-testing kits to gay men was feasible and acceptable.

Approximately 5000 tests were distributed during the six-week pilot and over two-thirds of those requesting the kits reported risky sexual behaviour.

Over 3000 men reported their test results via a secure webpage, with 28 (1%) of these individuals reporting a reporting a reactive result. Telephone contact was made with 22 of these men, all of whom had already sought a confirmatory test.

Self-testing for HIV: female sex workers

Sue Mavedzenge at IAS 2017. Photo by Roger Pebody, aidsmap.com

A series of presentations showed that self-testing is acceptable and feasible for sex workers in resource-limited settings.

Investigators reported on research conducted in Zimbabwe, Zambia, Uganda and Kenya.

HIV prevalence among female sex workers in Zimbabwe is as high as 50% but only two-thirds of sex workers are aware of their HIV status, with 43% taking antiretroviral therapy and only a third virally suppressed – well below the 90-90-90 target.

Self-testing was offered as an option to 600 women attending a specialist sexual health clinic for sex workers. Just over half – 54% – accepted. Testing wasn’t necessarily performed at home, indeed, most (96%) opted to use the testing kit in a dedicated room at the clinic. Just under a third had a reactive test, with 99% of those testing positive attending for a confirmatory test.

Follow-up questionnaires showed that all the women found the tests easy to use and trusted the result, and 98% said they were comfortable finding out the result with no one else there. Clinics were the preferred location for the distribution of the kits.

Randomised trials in Uganda and Zambia looked at the best way of distributing self-testing kits. Peer educators – all current or former sex workers – recruited other sex workers to the study. Participants were randomised into one of three study arms: direct distribution of testing kits; distribution of coupons which could be taken to a clinic or pharmacy for a kit; or standard of care, with the educator providing information on HIV testing services.

A thousand women were recruited in each country.

The study lasted four months and there were very high testing rates: 95-100% for direct distribution; 84-97% for coupon distribution and 87-89% for standard of care.

Linkage to care, however, was poorer among self-testers than those receiving the standard of care.

Research conducted in Kenya showed that text messages were a good way of promoting self-testing among female sex workers and male truckers.

Participants were sent reminders to test: those in the intervention arm were informed about the availability of self-testing, whereas individuals in the control arm were simply encouraged to test for HIV.

Among sex workers, 16% of those in the intervention arm compared to 6% in the control group tested for HIV, with 4% of truckers in the intervention arm also testing, compared to 1% in the control group.

Urgent action needed on treatment for cryptococcus

Sile Molloy at IAS 2017. Photo by Liz Highleyman, hivandhepatitis.com

Urgent action is needed to expand access to flucytosine, an antifungal drug used to treat cryptococcal meningitis in people living with HIV who have very advanced disease.

Results presented to the conference showed people treated with flucytosine had reduced mortality rates.

It’s estimated that 15% of HIV-related deaths (181,000) in low- and middle-income countries are caused by cryptococcal meningitis, and that 6% of people living with HIV who have a low CD4 cell count (below 100) are positive for the cryptococcal antigen.

The infection can be treated with a range of antifungal drugs: amphotericin B, fluconazole or flucytosine.

A two-week course of amphotericin B and flucytosine is the preferred therapy. Amphotericin B is administered by infusion in hospital. Access to flucytosine is severely limited in Africa.

Investigators compared several regimens that might be more feasible for use in sub-Saharan Africa in a randomised trial involving over 700 people recruited in four African countries between 2013 and 2016:

  • All oral: fluconazole plus flucytosine for 2 weeks.
  • One week: amphotericin B plus flucytosine, or fluconazole for seven days, followed by a further seven days of therapy with fluconazole.
  • Two week: amphotericin B plus flucytosine, or fluconazole for 14 days.

When used with amphotericin B, flucytosine was superior to fluconazole. One-week amphotericin B and flucytosine had the lowest ten-week mortality rate (24%).

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.

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.

NAM AIDS UPDATE JULY 19 2017

19 July 2017
High rate of non-alcoholic fatty liver disease in people living with HIV

High rate of non-alcoholic fatty liver disease in people living with HIV
Non-alcoholic fatty liver disease (NAFLD) is an umbrella term for a range of liver conditions caused by a build-up of fat in the liver. It is defined by the accumulation of fat in the liver and the presence of triglycerides (a type of fat) in liver cells, without there being another cause such as excess alcohol consumption.

NAFLD is increasingly common around the world, especially in Western countries. It occurs in every age group but especially in people in their 40s and 50s who are at high risk of heart disease because of such risk factors as obesity and type 2 diabetes. The condition is also closely linked to metabolic syndrome, which is a cluster of abnormalities including increased abdominal fat, poor ability to use the hormone insulin, high blood pressure and high blood levels of triglycerides. NAFLD can not only lead to liver problems, including fibrosis (scarring of the liver), but also to changes in the body’s metabolism, such as atherosclerosis (hardening of the arteries).

Until now, much of the liver disease occurring in people living with HIV has been associated with co-infection with hepatitis B or C, but NAFLD is emerging as a new concern for people who do not have hepatitis B or C.

A group of UK researchers have recently conducted a review of existing studies on NAFLD in people living with HIV who do not also have hepatitis B or C. They found that very little research had been done, identifying only ten relevant studies, conducted in North America, Western Europe and Japan.

Based on those studies, they estimate that around one third of people with HIV may have NAFLD – a higher rate than seen in the general population.

Looking into risk factors for NAFLD in people living with HIV, they found that people are at increased risk of it if they are overweight or obese (especially with a lot of fat around the waist), have type 2 diabetes, high fasting glucose levels, high blood pressure, high total cholesterol, low HDL cholesterol, high LDL cholesterol, or high levels of the liver enzymes ALT and AST.

Many of these risk factors are the same as in the general population. But the study highlights the link between raised levels of liver enzymes and NAFLD. Experts say that doctors should properly investigate persistently raised levels of liver enzymes, considering NAFLD as a possible cause.

It is important that NAFLD is diagnosed promptly so that lifestyle changes can be made in good time. While effective drug treatments for NAFLD are not yet available, the researchers call for people with HIV to be included in clinical trials for new drug treatments.

Gastric reflux and proton pump inhibitors
Gastric reflux is a common condition where acid from the stomach leaks up into the oesophagus (gullet). It can cause symptoms such as heartburn and an unpleasant taste in the back of the mouth.

It can be caused by hiatus hernia (when part of your stomach moves up into your chest) or by stress, smoking, coffee, alcohol, fatty or acidic foods, eating too close to bedtime, and by obesity or pregnancy. Gastric reflux can also be a side-effect of some medications used to treat HIV and hypertension.

One type of medication used to manage gastric reflux are known as proton pump inhibitors (PPIs). These drugs, including lansoprazole, pantoprazole and omeprazole, work by suppressing stomach acid production.

A new study suggests that PPIs should be used with caution in people with HIV. The researchers found that people who received long-term treatment with the drugs failed to gain CD4 cells and experienced more immune activation.

This was a small study, comparing 37 men living with HIV who used PPIs with 40 men living with HIV who did not use the drugs but were otherwise broadly similar. The men using PPIs had been using them for an average of three years.

Men using PPIs lost an average of 18 CD4 cells in the previous year, whereas those not using them had an increase of 54 CD4 cells. Those using PPIs had higher levels of sCD14, which is a marker of immune activation, in other words excess activity of the immune system.

The researchers say that doctors should use PPIs with caution until longer-term studies are completed. These studies should look into whether use of the drugs have any harmful clinical consequences. Research is also needed with women living with HIV.

Lower risk of heart problems with atazanavir
People who started HIV treatment with a drug combination containing atazanavir (Reyataz) were significantly less likely to suffer a heart attack or stroke than people starting treatment with other regimens, according to a recent study.

Atazanavir is a widely used protease inhibitor. Although HIV treatment reduces the risk of cardiovascular disease in people living with HIV, some protease inhibitors have been associated with an increased risk of cardiovascular disease compared to other treatment regimens. These include indinavir, lopinavir/ritonavir (Kaletra) and darunavir/ritonavir.

Atazanavir may have an advantage because its use is associated with smaller increases in LDL (‘bad’) cholesterol and total cholesterol than other protease inhibitors. In addition, atazanavir treatment also results in raised levels of bilirubin which do not cause symptoms but which may be associated with a reduced risk of heart failure.

An American study of 1529 people taking atazanavir and 7971 people taking other HIV medications has found that people treated with atazanavir were approximately 40% less likely to experience a heart attack or a stroke.

Low use of statins in Chicago
Meanwhile, a study from a large HIV clinic in Chicago shows that many patients there who are at high risk of heart disease are not getting the statin preventative treatment that they need.

People living with HIV who already had hardened or blocked arteries did mostly get statins (93%), in line with guidelines. Similarly, 56% of those who had diabetes received statins.

But only 29% of those who had not already had heart disease but who were judged to be at elevated risk of it were receiving treatment with statins. A person’s risk of heart disease can be calculated, based on factors like age, race, gender, cholesterol, blood pressure, diabetes and smoking.

This analysis was done on the basis of statin guidelines for the general population. People living with HIV are at greater risk of heart disease than HIV-negative people, but specific statin guidelines for people with HIV do not exist yet, partly because studies on the benefit of statins in people with HIV have not yet been completed. It is probable that future guidelines on preventing heart disease in people living with HIV will encourage a wider use of statins than in the general population.

 

THEBODY PRO UPDATE – JUNE 13TH 2017

Top Stories on TheBodyPRO.com: June 13, 2017
The Power of Positive Thinking Could Help Lower Viral Load

The power of positive thinking might extend well beyond emotional well-being to include physical benefits such as lower viral load in people with HIV, according to new research.

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This Week in HIV Research: Continuous Treatment Adherence Increases

This week, a study finds that continuous HIV treatment adherence, without a 90-day gap, has increased from 2001-2010, and is now longer than adherence to medications for some other chronic diseases.

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New Hepatitis C Infections Nearly Tripled Over Five Years

Over just five years, the number of new hepatitis C virus infections reported to CDC has nearly tripled, reaching a 15-year high, according to new data.

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Increased Prevalence of Diabetes in HIV-Positive People

Diabetes occurs at an increased frequency in people with HIV and may develop at earlier stages than it does in the general population.

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What’s Up With PrEP and STIs?

HIV Patients 65 Years or Older Face Higher Rates of Serious Non-HIV Illnesses

Poppers and Cancer Risk in HIV-Negative and HIV-Positive Gay Men

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THEBODY PRO – UPDATE JUNE 6TH 2-17

Top Stories on TheBodyPRO.com: June 6, 2017
In the Vanguard of HIV Vaccine Research

An interview with Dan Barouch, M.D., Ph.D., on the key challenges in vaccine development, potentially curing HIV and why we should be excited about antibodies.

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This Week in HIV Research: Spotlight on HIV Cure Research, and TAF vs. TDF in Triple-Drug Regimens

This week, we look at a special issue of The Journal of Infectious Diseases that highlighted HIV cure research.

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Can’t HIV Serodiscordant Couples Now Just Have Children the Regular Way?

Do mixed-status couples still need “sperm washing” to get pregnant if one is on suppressive ART and the other is taking PrEP?

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Transforming the HIV Workforce

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Next-Generation PrEP Trials: The Age of “Active Controls”

Emphysema Tied to Cough and Slower Walking With HIV but Not Without HIV

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THEBODYPRO NEWS UPDATE – MAY 30TH 2017

Top Stories on TheBodyPRO.com: May 30, 2017
Depression Not Tied to Mortality Risk in Current Treatment Era

Experiencing symptoms of depression had no impact on risk of all-cause mortality in a 2005-2014 U.S. study of people with HIV.

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How Can Providers Deal With Concerns About Risk Compensation in PrEP Users?

Some health care providers may have concerns that some PrEP users may increase their sexual risk-taking behavior because they feel less susceptible to HIV while taking PrEP.

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Main Barriers to Taking Meds Among Adults, Adolescents and Children

Simply forgetting to take antiretroviral pills, being away from home and a change in the daily routine headed the list of reasons for inconsistent antiretroviral pill taking in a 125-study analysis.

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Grip Strength Falls Faster in Older Men With HIV Than Without HIV

Grip strength fell faster after age 50 in men with HIV than in a similar group of HIV-negative men, according to a 7-year analysis in the U.S.

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Access Means More Than Co-Pays: PrEP Success for Transgender Women

HIV and Hepatitis C Not the Most Serious Infectious Threats to People Who Inject Drugs

Some Issues Related to Sexual Dysfunction in Men