Titanic Shift in Attitude Anticipated at AIDS 2016

Pam Harrison

July 08, 2016

DURBAN, South Africa — In the 16 years since the International AIDS Conference was last held in South Africa, there have been dramatic changes in attitudes about HIV.

"It's a different world now, but it's particularly a different world in South Africa," said Chris Beyrer, MD, MPH, from the Johns Hopkins Bloomberg School of Public Health in Baltimore, who is president of the International AIDS Society.

"In 2000, you had a political leadership that denied HIV was the cause of AIDS, and a Minister of Health who was talking about nutritional supplements, not antivirals," he told Medscape Medical News. And in 2000, "we still had not begun any serious commitment to global access to antivirals and the treatment era in Africa hadn't even started."

But now, South Africa has the largest treatment program in the world, and more than 3 million people are on therapy. And around the world, 17 million people are on antivirals, which is "really remarkable," Dr Beyrer reported.

Research has fueled enormous advances in the treatment of the disease. The Health Prevention Trials Network (HPTN) 052 study, presented at the meeting last year, as reported by Medscape Medical News, showed a sustained 93% reduction in HIV transmission within HIV-discordant couples when the HIV-infected partner was treated with antiretroviral therapy and viral suppression was adequate.

All HPTN 052 participants were subsequently offered therapy, and final data from this open-label phase will be presented this year.

It's a different world now, but it's particularly a different world in South Africa.

"We can't give up on primary prevention, and that now includes PrEP, so that's going to be a major theme in Durban," Dr Beyrer confirmed. In fact, final data from the Partners PrEP Study are expected to confirm just how effective it is.

Compelling data are also expected from the Sustainable East Africa Research for Community Health, or SEARCH, which set out to demonstrate that a population-based "treatment as prevention" strategy, involving 320,000 residents of East Africa, could shut down new HIV infections, along with tuberculosis (TB) and other infectious diseases.

A pivotal piece of science that might help reset the course of the HIV epidemic will come from vaccine research.

"The history of viral epidemics tells us that it's very rare, if ever, that a viral epidemic has been controlled without a vaccine," Dr Beyrer pointed out.

Initiatives in that area will be addressed by Larry Corey, MD, from the Fred Hutchinson Cancer Research Center in Seattle, in his plenary, which will likely include a report from the small pilot HVTN 100 trial, which is based on the RV144 trial.

In the RV144 trial, the experimental vaccine tested in Thailand was 31.2% effective at preventing HIV infection during 3.5 years of follow-up, although it was twice as effective in the year immediately after vaccination.

In the pilot HVTV 100 trial, the vaccine being tested is a "boutique" vaccine modeled on the Thai vaccine, but it has been tailored to fit the HIV virus circulating in Africa.

Focus on Clinicians

"In previous conferences, the needs of clinicians were not taken into consideration as much as they should have been," said Stefan Baral, MD, from the Johns Hopkins School of Public Health, who is part of the scientific committee for the International AIDS Conference 2016.

"But many sessions this year are focused on clinical decision-making as it relates to the best and newest models of care we can offer HIV-positive patients, as well as more options for prevention," Dr Baral told Medscape Medical News. Until now, physicians have had only one agent, the combination of tenofovir disoproxil plus emtricitabine (Truvada, Gilead Sciences), to offer as PrEP to high-risk, HIV-negative patients.

There are real contraindications to the older formulation of tenofovir, including osteopenia and poor kidney function, he pointed out.

A new combination of tenofovir alafenamide, the integrase inhibitor elvitegravir, the pharmacokinetic enhancer cobicistat, and tenofovir disoproxil fumarate plus emtricitabine could soon be a new PrEP option for patients with contraindications, he explained.

And for patients with adherence issues, new data on injectable PrEP will likely allow physicians to take a more nuanced approach to prevention.

The translation of pivotal clinical trials, such as START and TEMPRANO, into clinical practice will be emphasized at the meeting.

Next Steps After START and TEMPRANO

START and TEMPRANO showed that the initiation of antiretroviral therapy when CD4+ cell counts are at least 500 cells/mm³ helps patients to a greater extent than delaying treatment until CD4+ cell counts are below that level. Getting patients tested and treated early in the course of their infection is a key goal in the control of HIV, Dr Beyrer said.

The need to prevent and treat HIV coinfections, most notably TB and viral hepatitis, will also be addressed at the meeting. For people infected with HIV, morbidity and mortality are increasingly due to coinfections and comorbidities, not HIV itself.

Data will be presented on the treatment of multidrug-resistant TB in people coinfected with HIV, new direct-acting agents for the treatment of hepatitis C in patients coinfected with HIV, and hepatitis B viral suppression in pregnant women coinfected with HIV.

"Another focus at the meeting is on implementation science," which includes research studies done in real-world settings, Dr Baral reported. Clinicians might feel they can move forward with such findings because "the work was done in a clinic not dissimilar to their own."

Studies suggesting ways to improve patient care by recruiting allied health professionals, including social workers and case managers, will also be given their due.

And cutting-edge research on the use of high-tech strategies to cure HIV infection will be showcased before the official start of the meeting. The use of the CRISPR/Cas9 gene-editing system to eliminate the proviral genome from infected cells, as well as cells harboring latent virus, will be discussed.

Insights into the way allogeneic stem cell transplantation might reduce the HIV reservoir responsible for perpetuating the infection will also be featured, as will a look at whether PD-1 blockade can reduce the viral reservoir and help restore antiviral CD8 T-cell function.

An extensive noncommercial satellite symposium program has been organized as a run-up to the main meeting. Sessions will cover virtually all aspects of the pandemic, from who it affects, how it might be better managed, and the myriad social implications of living with HIV and protecting the uninfected.

Ending barriers for those in need and garnering political will to provide equity for all is the goal of the Second Durban Declaration: Access Equity Rights — Now!

"Durban 2000 was really the beginning of the treatment access era, and I would like to see Durban 2016 be the launch of the PrEP access era," Dr Beyrer said.

"What we want to do is maintain the energy, the enthusiasm, and the commitment of everybody — communities, scientists, donors, and governments — to stay with this battle," he added.

"We are not done yet, and we declare victory too soon at our peril, but there is every reason to be optimistic if we stick with it," he explained.

Dr Beyrer and Dr Baral had have disclosed no relevant financial relationships.


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