Adrian Castelli

As the final symposium of the Conference on Retroviruses and Opportunistic Infections (CROI) begins, and after hearing about all of the new research predominantly in HIV over the last 4 days, it’s hard not to wonder where it’s all pointing. Fortunately, one of the final symposia sought to provide an answer - ART: The Next 25 Years.

The general themes discussed at the conference would be to say that in general, we are doing quite well with controlling incidence of HIV in MSM in the developed world, the caveat being hot-spots of predominantly Black and Latinx men, or White guys who inject drugs. We’re not doing so well with women in general, particularly in the African setting, and the pregnancy/post-partum complex is perhaps more ominous that we’d initially thought. All of this is constructive, however, and allows us to check the temperature, so to speak, and re-evaluate our approaches to HIV management. 

There is continuing controversy about the clinical effect of HIV in the brain. This session sought to examine the effects of cART, started early or not, on both the physical health of the brain and mental health of the patients. 

• The World Health Organisation considers depression to be the leading cause of disability globally, with anxiety rating 6th. 
• 4.4% of the world’s population is thought to be living with depression, but estimates show that at least 50% of people living with HIV/AIDS (PLWHA) satisfy criteria for at least 1 mental or substance use disorder.
• Risk-associated behaviour and poor health care adherence increases in people with depression particularly.
• Depression is the most prevalent mental illness amongst PLWHA.
• Mortality rates in PLWHA diagnosed with a Major Depressive Disorder (MDD) are double when compared with those not diagnosed with MDD.
• Lengthier durations of MDD are associated with increased mortality, and this is thought to be due to chronic inflammation causing tryptophan deficiency and as a result serotonin deficiency.
• Meta-analyses show adherence to the HIV model of care in PLWHA with depression is a significant barrier to treatment (15% adults, 25% in adolescents). 
• Whilst multiple validated screening tools exist for mental illness and multiple modes of therapeutic intervention also exist these are not being employed reliably.

• The rates of HIV in IVDU decreased in the US by 34% in the last decade but then stalled in 2015.
• Sexual behaviour was associated with new infections of HIV in the IVDU community.
• Intentional misuse of prescription opiates are associated with a rapid transition to injecting drug use, particularly with heroin.
• The majority of drug overdoses related to IVDU with HIV were considered accidental and in patients who were retained in care.

At A Glance:

• Using genotype resistance assays (GRAs) to establish hot spots of increased HIV incidence finds young Latinx MSM disproportionately high across 60 clusters.
• Phylogenetic studies show that whilst treatment-as-prevention (TaSP) is increasing and effective amongst Swiss MSM, increasing risk-associated behaviour is associated with HIV cluster growth.
• Transgender women cluster predominantly with other trans women, cisgender men but less than expected with MSM.
• Hotspots in an African phylogenetic study show that most genetically linked infections in surrounding regions come from within the hotspot and are responsible for ‘dispersion’ of HIV into greater geographical locations.
• Successive cross-sectional surveys in conjunction with incidence data from the CDC yields the same results in incidence surveillance than the more expensive gold standard prospective cohort study model.
• Incidence of HIV increases per sex act almost 3-fold in pregnant women and almost 4-fold in the post-partum period.

The changes in management of Hepatitis C virus (HCV) has been an interesting and rewarding time for those of us who have treated patients that ultimately achieve sustained virological response (SVR) or ‘cure’, but there are still some tricky clinical situations that can cause some consternation, including infants and teenagers as the new face of HCV, how to manage an acute infection and what to do with resistant strains.

"Research without community is not good research": Dr Sharon L Hillier of the University of Pittsburgh says if we are to continue to make strides in the management of HIV and toward eradication then the research is going to have to include the communities affected by what she refers to not only as a chronic but a social disease.