2018 HIV Drug Therapy HIV

A report on Sarah Fidler’s presentation “Approaches towards a cure for HIV” 

Sarah Fidler opened her lecture on HIV cure by provocatively asking – with the advances in drug therapy in the last decade, do we even need a cure? Of course with the financial costs of ARVs in addition to the potential impacts of ageing with HIV, a cure is ideal. 

The sterilising cure, used 9 years ago in the Berlin patient, has been thus far unreproducible. Redefining our expectations is an important first step to recognise the potential for products in the pipeline. Aiming therefore for a “functional cure”, one with a very low sustained viral load, could be achievable. This would allow for host control of viral replication without continued treatment, immune function restored, as well as stabilised, HIV-induced inflammation reduced, and very low risk of transmission to others. 

A report on Julia Del Amo’s presentation “HIV and Migration: a renewed challenge”

Julia del Amo challenged our assumptions about HIV and migrants, with particular focus on Europe. Some migrants arrive to their destination country already living with HIV, either acquiring it in their port of origin or during their journey. However, the number of men who acquire HIV after they migrate is startling. 

There are steadily increasing numbers of MSM who are diagnosed within the first year of living in their destination country (up 58% since 2007), while people who are heterosexual and newly diagnosed is declining (down 36% from 2007).  Moreover, in migrants from sub-Saharan Africa who are found to have HIV a year after arrival, approximately 72% of MSM and 50% of heterosexual migrants acquired HIV post-migration. This is determined using a validated method of estimating acquisition. 

A report on Julia Del Amo's presentation "HIV & Migration: a Renewed Challenge"

Since 2015, Europe has been in the grip of a “Migrant Crisis”¹ , shifting the population landscape in some countries and a change in the political climate.

As Julia Del Amo from the National Center for Epidemiology, Institute of Health Carlos III, Madrid explained in her session “HIV & Migration: a Renewed Challenge”, the UN definition of a migrant is incredibly broad² and this is reflected in the challenges that are faced domestically, politically and economically when considering these groups. She delivered an enlightening presentation on Wednesday morning at the Glasgow 2018 conference outlining patterns of HIV such as country of origin for newly acquired HIV cases & HIV positive migrants in Europe; acquisition method and trends in HIV positive migrants from specific regional ‘hotspots’. 

Of course, the situations in Europe and Australia greatly differ. With strict border controls and compulsory HIV testing when applying for permanent visas, it could be argued that this data does not apply to us – and certainly Australia has some of the lowest rates of HIV positive migration in the world. But there would be few Clinicians among us who do not have patients who have migrated either legally or illegally to this country and there were many elements of this presentation that could be translated into greater awareness and care for this cohort.

A report on Sarah Fidler's presentation "Approaches towards a cure for HIV"

This presentation, on the third day of the conference was one of the best attended - with an entirely packed auditorium. As a Clinical Trials Coordinator, the question of a cure comes up on a regular basis in my work. Even though we now have U=U, and with most patients having a very small burden, there are still those who yearn to be pill and disease free.

A report on Catia Marzolini's presentation "The top 10 DDIs in day-to-day clinical management of HIV"

In this session Catia Marzolini from the Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland gave a presentation titled ‘The top 10 DDIs in day-to-day clinical management of HIV’.

It is well known that HIV-infected patients may be at risk of a clinically significant drug-drug interaction (DDI), since antiretroviral drugs are recognised to be amongst the therapeutic agents with the highest potential for DDIs. In this session, the drug-drug interaction potential of antiretroviral drugs was discussed with interactions occurring at drug metabolism, drug excretion or drug absorption. The common mechanisms identified for these interactions were inhibition or induction of drug metabolising enzymes or drug transporters as well as chelation with polyvalent actions or pH-dependent changes in drug absorption. The antiretroviral agents were categorised into either victim drugs or perpetrator drugs, with some agents acting as both victims and perpetrators.

A report on Chloe Orkin's presentation in the session "Challenging Cases in HIV Prevention and Management in collaboration with the International Antiviral Society-USA (IAS-USA)"

A session regarding initiating antiretroviral therapy (ART) was presented by Chloe Orkin from Barts Health NHS Trust and Queen Mary University of London, London, UK. Chloe Orkin is also the current Chair of the British HIV Association (BHIVA). The presentation was titled ‘Case 2: ART – initiating treatment’ in a section of the conference called ‘Challenging Cases in HIV Prevention and Management’ in collaboration with the International Antiviral Society-USA (IAS-USA).

In this presentation Chloe Orkin presented 3 cases of first line ART – What to start, Rapid ART and ART in pregnancy. For this post I have elected to concentrate on the ‘What to Start’ section of this presentation.

A report on Alexandra Calmy's presentation "New ARV drugs and strategies"

In this session Alexandra Calmy from the HIV/AIDS Unit, Geneva University Hospitals, Geneva, Switzerland delivered a presentation titled ‘New ARV drugs and strategies’ in the final Late Breakers/Hot Topics section of the Conference.

Alexandra Calmy covered a significant amount of information in this session, commencing with drugs in the pipeline. She discussed the issue that the global need for better HIV treatment means that data to inform their use in all settings are needed. Here she made reference to the gaps in data for the use of dolutegravir in certain clinical situations.

Another issue presented was the two safety alerts related to the use of antiretrovirals during pregnancy in 2018. The first being the risk of birth defects in babies born to women taking dolutegravir, and the second the new contraindication against using darunavir/cobicistat during pregnancy due to the significantly reduced plasma levels of darunavir and cobicistat during the second and third trimesters of pregnancy.

A report on Caroline Foster’s presentation “Adolescent lives matter: Staying with it - novel ways to increase adolescent adherence” 

In this presentation Caroline, who works at the 900 Youth Clinic at St Mary’s Hospital London, spoke specifically about the challenges around adherence with HIV-positive young people aged 16-24 who are either newly diagnosed or transitioning from children’s services.  

One of my key learnings from this session is that poor adherence in adolescents is normal, with poor adherence in those on ARVs at around 20% in London. Adherence patterns are also similar across disease types. For example, this pattern of reduced adherence in PLWH around puberty and the teenage years is equally matched with those living with Type 1 Diabetes Mellitus, corroborated by reduced glucose control during such years. 

A report on Erica Peter's presentation "Interactive Case Study: HIV-HCV and PWIDS"

Dr Erica Peters, a local Glasgow ID physician, has seen a disturbing rise in the incidence of HIV (133 in the last few years, 1/3 women) in the population of people who inject drugs in Glasgow: many are co-infected with HCV. This population poses challenges for decision-making on drug therapy given that many people in this population are both taking both prescribed and recreational drugs.

A report on Simon Rackstraw’s presentation “Factors associated with HIV-associated neurocognitive disorder in an unselected cohort in East and South London: the HAND study” 

This presentation demonstrated the findings from a prospective study in which 786 people living with HIV (PLWH) aged >18 were recruited from four HIV clinics across East and South London to determine: 

a) the extent of neurocognitive impairment (NCI) within the cohort, and
b) to establish correlation with HIV-related factors and medical co-morbidities.