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IDWeek 2016: Do HIV-Positive Men with Undetectable Viral Load Need to Wear Condoms?

In the face of extensive research showing that HIV-positive people on antiretroviral therapy (ART) with stable undetectable viral load have an extremely low likelihood of transmitting the virus, a majority of participants at IDWeek 2016 in New Orleans thought they should still be advised to use condoms -- a proportion that actually increased after a debate that laid out the evidence.

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HIVR4P 2016: Huge Diversity in HIV Vaccine Research Discussed at Prevention Conference

The HIV vaccine research field is currently going through probably its most fertile and diverse period yet. A high proportion of presentations at the second HIV Research for Prevention conference (HIVR4P 2016) in Chicago last week were devoted to a multiplicity of different approaches scientists are taking towards making an effective vaccine.

[Produced in collaboration with aidsmap.com]

At the opening plenary, Georgia Tomaras of Duke University gave an overview of the field. It has been a long journey towards developing vaccines with even partial efficacy: the first trial of any kind was in 1987 and the first large efficacy trial -- which failed -- was in 2003. But the RV144 vaccine -- which in 2009 showed limited efficacy, reducing HIV infections among recipients by 31% (and 60% a year after its first dose) -- injected new energy into the field, not least because its effect seemed due to an unexpected kind of anti-HIV response.

At the International AIDS Conference (AIDS 2016) held in Durban in July researchers reported that a pilot study, HVTN100, of an RV144-type vaccine adapted to the strain predominant in South Africa it produced a stronger response than the original RV144 vaccine. This meant it had passed the criteria for being advanced to a large efficacy trial, HVTN 702. This will start next month -- the first HIV vaccine efficacy trial for 7 years, since HVTN 505 started in July 2009.

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IDWeek 2016: Electronic Health Records Can Help Select Candidates for HIV PrEP

A machine learning algorithm used to analyze electronic health records (EHRs) identified high-risk individuals who could potentially benefit from HIV pre-exposure prophylaxis (PrEP), according to a report presented this week at IDWeek 2016 in New Orleans. Out of 800,000 patients in a large EHR database, more that 8000 were found to be potential PrEP candidates.

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HIVR4P 2016: Rings, Films or Inserts? Prevention Products Need to Make Sense in Women's Lives

"We need to think outside of the box," Sharon Hillier of the Microbicide Trials Network told participants at the HIV Research for Prevention (HIVR4P 2016) conference this week in Chicago. Researchers should not be aiming to develop the most scientifically elegant solution for HIV prevention, but should "figure out how to make products that can really fit into people’s lives."

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IDWeek 2016: Only a Small Proportion of HIV+ Gay Men Receive Anal Cancer Screening

In the absence of national screening guidelines, only 11% of HIV-positive gay and bisexual men in the U.S. received anal Pap smears to detect anal cancer or precancerous cell changes during 2009-2012, with disparities between patient groups and variations across centers, according to a presentation at IDWeek, taking place this week in New Orleans.

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HIVR4P 2016: New Microbicide Enema Achieves High Levels of Drug in Rectal Tissues in Monkeys

Rectal microbicides that protect against HIV transmission via anal sex are a bigger technical challenge than vaginal ones. The rectal lining is more delicate than the vaginal lining, so safety has been an issue; research has shown that many of the gel formulations used in lubricants damage rectal cells and may actually enhance HIV transmission.

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HIV Glasgow: French Study Reveals Growing Complexity of Medical Needs as People with HIV Age

The complexity of the needs of people living with HIV will continue to increase as the population ages, and clinicians need to go beyond thinking about co-morbidities to consider multi-morbidities -- clusters of medical conditions that complicate one another -- when caring for these people, Edouard Battegay from the University Hospital Zurich told attendees at the International Congress on Drug Therapy in HIV Infection (HIV Glasgow) this week.

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Coverage of HIV Research for Prevention Conference (HIVR4P 2016)

HIVandHepatitis.com coverage of the 2016 HIV Research for Prevention Conference (HIVR4P 2016), October 17-21, in Chicago.

Conference highlights include current and experimental pre-exposure prophylaxis (PrEP), microbicide rings and other options, and investigational HIV vaccines.

Full listing of coverage by topic

HIVR4P 2016 website

10/22/16

HIV Glasgow: Dolutegravir and Central Nervous System Side-Effects -- Abacavir, Older Age Increase the Risk

Insomnia, dizziness, headache, and other central nervous system (CNS) side effects are occurring more frequently with everyday use of dolutegravir than clinical trials had suggested, and are most likely to occur among women, people over age 60, and people starting abacavir at the same time, a German research group reported at the International Congress on Drug Therapy in HIV Infection (HIV Glasgow) this week.

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HIVR4P 2016: Vaginal and Rectal Bacteria May Influence HIV Transmission and Microbicide Efficacy

A number of presentations at the HIV Research for Prevention Conference (HIVR4P 2016) this week in Chicago looked at the influence of vaginal bacteria on HIV susceptibility, with one study finding that vaginal bacteria may have profound effects on levels of certain drugs used as microbicides -- but not others. A poster at the conference also looked at bacteria in the rectum in gay men, finding a correlation between condomless anal sex and changes in the predominant bacterial species which may similarly increase susceptibility to HIV infection.

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IDWeek 2016: Ibalizumab Monoclonal Antibody Looks Promising for HIV Patients Left Behind

Ibalizumab, an experimental antiretroviral agent that works differently than existing HIV drugs, demonstrated promising safety and antiviral activity in a small Phase 3 study of people with highly drug-resistant virus, according to a report at the IDWeek conference this week in New Orleans. If confirmed in larger studies, this could be good news for HIV patients who cannot be successfully treated using available therapies.

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HIVR4P 2016: Policymakers' Inaction is Leading People to Take "PrEP in the Wild"

An increasing number of gay men and others at risk for HIV are seeking to protect their health with pre-exposure prophylaxis (PrEP), but the lack of PrEP provision and regulatory approval in many countries is leading people to take it without medical supervision and on an ad-hoc basis. This will undermine the safety and effectiveness of PrEP, said Jerome Galea as he presented results of the PrEP in the Wild survey at the HIV Research for Prevention conference (HIVR4P 2016) this week in Chicago.

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HIV Glasgow: 2-Drug HIV Therapy Just as Effective as Standard 3-Drug Therapy

Simplification of antiretroviral treatment to a boosted protease inhibitor and the nucleoside analog lamivudine -- a dual regimen -- is highly effective for people switching from a stable 3-drug regimen, researchers reported this week at the International Congress on Drug Therapy in HIV Infection (HIV Glasgow).

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HIVR4P 2016: More Viral Suppression Needed to Reduce HIV Infections Among Gay Men

HIV suppression on antiretroviral therapy (ART) would need to increase substantially among men who have sex with men in order to take advantage of "treatment as prevention" to reduce the rate of new HIV infections, according to a mathematical modeling study presented at the HIV Research for Prevention conference (HIVR4P 2016) taking place this week in Chicago.

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HIVR4P 2016: Some Americans Who Need PrEP the Most Face the Greatest Barriers

The personal values and moral judgments of healthcare providers are likely to interfere with the appropriate provision of HIV pre-exposure prophylaxis (PrEP), Sarah Calabrese of Yale University reported at the HIV Research for Prevention conference (HIVR4P 2016) in Chicago last week. This was one of several presentations which highlighted inequalities in access to PrEP in the U.S. In a plenary talk, Noël Gordon of the Human Rights Campaign reminded delegates that white people make up 27% of new HIV diagnoses but 74% of PrEP users. There are also inequalities in terms of age and gender.

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HIVR4P 2016: Second Case Report of PrEP Failure Due to Drug-Resistant Virus

A PrEP user in New York City has become HIV-positive with virus that is resistant to Truvada and other antiretroviral drugs, according to a report presented Tuesday at the HIV Research for Prevention (HIVR4P 2016) conference in Chicago. This is only the second such case that has been reported, highlighting the rarity -- but not the impossibility -- of HIV infections among people who adhere to their pre-exposure prophylaxis (PrEP) medication schedule.

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HIVR4P 2016: PrEP Knowledge and Use Increases in San Francisco, 12,500 People Now on PrEP

Knowledge about and use of HIV pre-exposure prophylaxis (PrEP) has greatly increased over the past few years in San Francisco, and surveillance estimates suggest that some12,500 people are now on PrEP, according to a presentation at the HIV Research for Prevention conference (HIVR4P 2016) last week in Chicago.

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Life Expectancy for People with HIV Increases, But Does Not Match HIV-Negatives

People with HIV are living longer thanks to improvements in treatment, but life expectancy varies substantially across countries and even people who start antiretroviral therapy early have about an 8-year shorter life expectancy, on average, than the HIV-negative general population, according to recently published reports.

The advent of effective antiretroviral therapy (ART) in the mid-1990s dramatically reduced HIV-related mortality and increased survival for people living with HIV worldwide. Some studies have suggested that HIV-positive people who receive prompt treatment in countries with good access to care can have a life expectancy similar to that of HIV-negative individuals. But many people -- especially those who contracted HIV earlier in the epidemic and those in resource-limited countries -- may have reached very low CD4 T-cell counts before starting treatment and may have use poorly tolerated older antiretrovirals, leading to long-term detrimental health consequences.

Life Expectancy Among People in Care

As described in the September 1 Journal of Acquired Immune Deficiency Syndromes, Julia Marcus from Kaiser Permanente Northern California and colleagues aimed to determine whether a survival gap remains between HIV-positive and HIV-negative individuals with similar access to care.

The researchers conducted a cohort study of members of Kaiser Permanente California -- a non-profit integrated managed care organization -- using abridged life tables to estimate the expected number of years of life remaining at age 20.

The analysis included 24,768 HIV-positive and 257,600 HIV-negative Kaiser participants in care during 1996-2011.

There were a total of 2229 deaths among HIV-positive people, yielding a mortality rate of 1827 per 100,000 person-years (PY). Among HIV-negative people there were 4970 deaths, for a death rate of 326 per 100,000 PY.

Life expectancy among people with HIV increased over time. During 1996-1997, HIV-positive people at age 20 could expect to live 19.1 more years -- much less than the 63.4 years for HIV-negative individuals.

Life expectancy for HIV-positive people at age 20 increased to 47.1 years in 2008 and to 53.1 years in 2011, while it stayed about the same for HIV-negative people (64.9 years in 2011), narrowing the survival gap from 44.3 years in 1996-1997 to 11.8 years in 2011.

However, some groups had a shorter life expectancy, including African Americans and people with a history of injection drug use (45.8 and 46.0 more years at age 20, respectively, during 2008-2011). In contrast, white people, Hispanics, gay men, and heterosexuals had longer life expectancies (50.4, 52.2, 51.1, and 51.3 more years, respectively). Life expectancy at age 20 was similar for women (50.5 years) and men (49.2 years) -- notable because women in the HIV-negative population live longer than men, on average.

Among people who started ART early, with a CD4 count of 500 cells/mm³ or higher, life expectancy at age 20 was 54.5 years during 2008-2011 (vs 49.3 for all people with HIV), narrowing the gap to 7.9 years less than the HIV-negative population. Within this group, life expectancy increased further among people who did not smoke (56.9 years), did not have drug or alcohol abuse problems (55.7 years), and were not coinfected with hepatitis B or C (55.1 years).

"Even with early treatment and access to care, an 8-year gap in life expectancy remains for HIV-infected compared with HIV-uninfected individuals," the study authors concluded.

"These findings confirm that ART has had a substantial impact on the survival of HIV patients, and suggest that early ART initiation and risk reduction strategies, such as smoking cessation, may further reduce the remaining gap in survival relative to HIV-uninfected individuals," they added. "As lifespan lengthens and AIDS-related deaths decline among HIV patients, the impact on survival of smoking and other risk factors is likely to increase."

Life Expectancy Across Countries

In a related study, published in the August 31 advance edition of HIV Medicine, Sirinya Teeraananchai from the Kirby Institute at the University of New South Wales and colleagues did a meta-analysis of life expectancy after starting HIV treatment in countries with different income levels.

The authors identified 8 cohort studies, with a total of 154,670 participants, from the U.S., Canada, Europe, the U.K., Rwanda, South Africa and Uganda. Studies in high-income countries included mostly gay men, while those in low-income countries had a more even mix of men and women. Participants started ART with relatively low CD4 counts overall, between 100 and 300 cells/mm³.

The studies estimated life expectancy among HIV-positive people initiating combination ART at age 14 or older, again using abridged life tables. The researchers calculated pooled estimates of life expectancy overall and by country income level.

HIV-positive people in high-income countries had a life expectancy of 43.3 more years if they started ART at age 20 and 32.2 more years if they started at age 35. In low- and middle-income countries, however, life expectancy fell to 28.3 years at age 20 and 25.6 years at age 35.

Life expectancy was similar for men and women in high-income countries -- as seen in the Kaiser Permanente study -- but in low- and middle-income countries men starting ART at age 20 had a shorter life expectancy than women (22.9 vs 33.0 more years).

At all income levels life expectancy increased over time, likely reflecting improvements in ART, guidelines recommending earlier treatment, better adherence and support programs, and scale-up of treatment access.

10/18/16

Sources

JL Marcus, CR Chao, WA Leyden, et al. Narrowing the Gap in Life Expectancy Between HIV-Infected and HIV-Uninfected Individuals With Access to Care. Journal of Acquired Immune Deficiency Syndromes 73(1):39-46. September 1, 2016.

S Teeraananchai, SJ Kerr, J Amin, et al. Life expectancy of HIV-positive people after starting combination antiretroviral therapy: a meta-analysis. HIV Medicine. August 31, 2016 (online ahead of print).

HIV Glasgow: New $90-$90-$90 Target Needed for Global Viral Hepatitis, HIV, and TB Treatment

The costs of making drugs to treat viral hepatitis, HIV, and tuberculosis (TB) are now so low that each disease could be treated for less than $90, Andrew Hill of St. Stephen’s AIDS Trust said at the opening plenary of the International Congress of Drug Therapy in HIV Infection this week in Glasgow.

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HIVR4P 2016: Anal Sex May Transmit 4 in 10 HIV Infections Among High-Risk U.S. Women

A study presented at the HIV Research for Prevention conference this week in Chicago suggests that among women at high risk for HIV infection, 40% or more infections might be transmitted via anal intercourse. Because HIV is transmitted, according to different estimates, from 2 to 18 times more easily via anal than vaginal sex (the Centers for Disease Control and Prevention's estimate is 12 times), anal intercourse could be a major -- or even predominant -- contributor to HIV infections in heterosexual women, even if anal sex accounts for only 5%-10% of all sex.

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