ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Martin Holt presented interesting results from the Australian PrEPARE Project.

Overall the results seemed to lean towards willingness to use PrEP being amongst the minority of people in the MSM population, with the willing parties mainly being in the high risk group of contracting HIV.  These high risk men most willing to use PrEP are with those with HIV positive partners and inconsistent condom users.

Interestingly, the study also looked at men who were willing to have sex with a PrEP taker. People in this group were mainly those who were positive themselves, or who had a HIV positive partner, rather than those who are having casual sex with multiple partners. 

Really interesting! I can't wait to see what happens as more people start taking PrEP as it becomes more freely available! Maybe it will become more widely accepted. 

Posted by on in HIV Cure, eradication of HIV

Brent Allan spoke on the jading effect he feels, with the constant media reports of HIV "cures". He started by asking for a show on hands, to indicated how long it would be, before a cure would be available. The majority of the audience voted for 10-15 years.

He read several headlines from news report, published in the last week. These included "Cairns to trial HIV drug cure" which turned out to the trialling of PrEP. Unfortunately most of these headlines were from respected news agencies, which generates online discussion and the resulting analysis has a demoralising effect.

Brent also identified the need to provide hope for newly diagnosed HIV, even with these headline grabbing misinformation.

The session ended with an interesting question to the audience. If we expect a cure in 10-15 years, then what are we doing to help people living with HIV to transition to life without HIV? As positive as living without HIV sounds to me, for some who have lived with the virus for 20+years, they may lose their identify. 

Anthony Fauci from the National Institute of Allergy and Infectious Diseases (NIAID) & National Institute of Health (NIH), Bethesda, USA, presented an excellent keynote lecture on ending the HIV/AIDS pandemic.

He started by taking us through a timeline of HIV infection. Starting in the 1980s, when the mean life expectancy of a newly diagnosed 20 year old (not on ART) was ~12 years. We followed the science through time and today, over 35 years later, the mean life expectancy of a newly diagnosed 20 year old (on ART) is ~53 years.

What we've learned since the 1980's regarding the etiology, virology, pathogenesis, treatment and prevention have given us a better understanding on how all these advances should continue to be used in conjunction in order to end the HIV/AIDS epidemic.

We've discussed treatment as prevention (TasP) and looked at a traid of pivotal ART studies regarding the treatment of individuals with HIV infection:

  • The SMART study showed that episodic ART is inferior to continuous ART
  • The HPTN 052 study showed that early ART reduces HIV transmission to uninfected sexual partners by 93%
  • The START study showed that early ART reduces serious illness or death by 57%

 

We are all aware of the continuum of care when our patients have a positive HIV test results, but we should also be very proactive in the continuum of prevention in those who test negative.

Despite our 90/90/90 targets, the numbers of newly diagnosed HIV infection have plateaued globally since 2009.

Continuing to improve access to ART and HIV prevention strategies, such as pre-exposure prophylaxis (PrEP) could dramatically decrease HIV-related deaths and the rate of new HIV infections.

The efficacy of PrEP has been proven in multiple studies and most recently the San Francisco Strut PrEP program showed no new HIV infections in >1200 men on PrEP in nurse-lead intervention over nearly 1.5 years. There were 82 new infection at that clinic among men not enrolled in the PrEP program.

The two main remaining scientific challenges for HIV identified are:

  • Addressing HIV persistence
    • eradicate the reservoir - classic "cure"
    • control viral rebound - sustained virologic remission
  • Development of a safe and effective preventative HIV vaccine 

Towards a HIV vaccine:

  • The first signal of efficacy (31%) in a HIV vaccine clinical trail - RV144, was seen in: Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. S Rerks-Ngarm, et al. For the MOPH-TAVEG investigators. N Engl J Med 2009; 361:2209-2220. Dec 3, 2009
  • Additional work since this study has lead to a large-scale HIV vaccine trial that will launch in November 2016 in South Africa: HVTN 702 modifeid RV144 prime-boost regime
  • More work is also being done on Neutrolising Monoclonal Antibodies, discovered since 2009.

 

Conclusion:

Treatment + non-vaccine prevention + vaccine = durable end of the HIV/AIDS pandemic

What a fascinating and informative first day on a beautiful, if a little bit cold Autumn Glasgow day!

In one of the early sessions, Ian McGowan of University of Pittsburgh discussed innovations in long acting ARV's for both HIV treatment and HIV prevention (PrEP).

Phase 2 studies for intramuscular injections and implantable devices look promising and are now moving into phase 3.

The combination of two long-acting injectable antiretrovirals, cabotegravir and rilpivirine given once every 4 or 8 weeks;

. were generally well tolerated treatment regimens

. maintained viral suppression  in HIV positive patients 

. prevented HIV in negative patients. 

. had high patient satisfaction levels

Sally Jewsbury of Manchester NHS foundation trust followed with a complex and difficult case study presentation involving a female Zimbabwean patient with multiple co-morbidities that ultimately had a happy ending due to her and her teams dedication and perseverance. I had the pleasure of meeting Sally personally during lunch. 

A moving tribute was made to Joep Lange and Jacqueline Van Tongeren followed by an inspirational presentation by Anthony Fauci from US National Institute of Allergy and Infectious Diseases. His focus was on implementing proven scientific tools to end the HIV/AIDS pandemic, highlighting the great advances made since the first  HIV notifications in 1981.

African Vaccine Dreams

Everyone's intrigued by it, every country is keen for it, apparently even the CIA wants it. The room brimmed with academic excitement as we gathered to hear a panel discussion on the prospects of an HIV vaccine and how "vaccines are needed to conclusively end HIV/AIDS and TB".

Six major trials have been conducted in the past, looking at potential HIV vaccines, but so far the results have been disappointing. The most successful vaccine trial was the RV144 study in Thailand, but this vaccine was only modestly protective against HIV infection.

The HVTN 702 trial is due to commence in South Africa towards the end of 2016, but scientific research is expensive and a phase three vaccine trial costs approximately $135million.

It's proving difficult to produce a vaccine for HIV. There are not only challenges with the science, but also with policies, politics and funding. We need international collaboration if we're ever going to create an HIV vaccine that works.

We already have a vaccine for Tuberculosis but it's more than 95 years old and not very effective. There's been little interest, investment or pharmaceutical support for a new TB vaccination and the research already performed has only yielded disappointing results.

Ruth Labode (Parliamentarian of Zimbabwe) was asked if politicians are growing cynical of ever getting an HIV vaccine and is this affecting TB and HIV research. She responded that when she hears a church minister saying "let's pray that we find a vaccine for HIV", she thinks the minister should be praying “for those who are on treatment, to stay on treatment".

She has a point. It’s important to plan for the future, but remember we already have medication that works - let's use it.

Ruth Labode stated “African countries need to come together as an informed community to collaborate with their international partners”. Her opinion is that Zimbabwe is not investing enough money into scientific research and development. “We always worry about money, but at the end of the day the epidemic is not in recession".

The panel was asked their opinion about how to get people excited about a vaccine, but continue to have a measured scientific approach. Peter Godfrey-Faussett (UNAIDS) passionately responded by saying “everyone’s talking about the UN's 90/90/90 targets for HIV, now even TB has a 90/90/90 target, but sometimes we don't quite understand what we're talking about. When we're talking about HIV we really need three ZEROS - zero HIV-related deaths, zero new infections and zero HIV-related stigma".

"Our current 90/90/90 targets relate to HIV treatment and it's working because we're seeing that the number of people dying from HIV is reducing. Some countries are nearly at 90/90/90 targets. Australia has recently announced that they're already at 90/90/90, but in some areas of the world HIV diagnoses are going up. 90/90/90 is a popular catch phrase, but people forget that it's only one of 10 targets the UN has mentioned. Millennial goals have become sustainable goals, but now we need a specific target for TB".

Peter Godfrey-Faussett continued “Where does research and development come into this? Domestic governments are putting money into it and domestic resources are going up. Economists talk about "discounting" - would you rather have 50 Rand today or 100 Rand in 20 years time? Do we deal with things today or do we invest in things for the future? Of course we need both and we need to balance this".

He proposed "We need more than just treatment. A quarter of funds should be put into prevention.” A successful mosaic vaccine is more likely to arrive sooner if countries collaborate and share the load.

But vaccines don't just come in a syringe. Condoms, male circumcision and PrEP all decrease HIV transmission. PrEP is especially effective at preventing HIV but we're still not promoting it as well as we could be.

Glenda Gray (South African Medical Research Council) was asked what African-led science would look like in the future. Her response was simply that African governments don't fund enough science. "Until African countries see the value of funding medical research, we will always be behind. Our budget is puny compared to other organisations like the Bill and Melinda Gates Foundation" she said. "We need our government to support science. Science is slowly emerging in South Africa, but it's still not good enough. We need to see a renaissance of science in Africa. If you want a healthy country, you need to invest in Research and Development."

Mark Feinberg (International AIDS Vaccine Initiative) was asked to reflect on the pharmaceutical industry. He stated that people still think the pharmaceutical industry "only gets involved when there is a payback, but industry is evolving [to a place] where collaborative efforts can go ahead and answer big questions. Scientific challenges and the challenge of scientific partnerships is an area where there is incredible potential. Organisations need a pathway and direction to take them to a much greater scale". He stated that we all learnt a lot from the international efforts with Ebola and this has shown us a much different way of dealing with these big issues in a collaborative way.

Countries respond very differently to dealing with TB and HIV. Fragmented systems of care exist where health professionals are either concentrating on TB or HIV, but we need to be treating both. The general population doesn't equate TB with death like they used to do many years ago and there's currently a lack of engagement from the community. We don't provide aggressive case management and we lose patients to follow up. We have incredibly rigorous surveillance with our HIV patients, but we need to have the same approach with TB.

The panel was asked if scientific research and development funding would increase as we continue our search for an HIV vaccine. Glenda Gray replied "South Africa does fund HIV vaccine research, but the funding from the National Institutes of Health (NIH) is a thousand-fold more than what South Africa is funding. It's like South Africa isn't serious about its funding towards an HIV vaccine. We've been able to improve South Africa's life expectancy by 9 years due to aggressive antiviral therapy, but to fuel our economy we need to fund research & development." She continued “We need to harness an economy of knowledge, but we are short-sighted in our vision. We need science like we need clean water."

Dr Anton Pozniak (my new professional man-crush) stood up from the audience, took the microphone and addressed the panel. “There's currently a gross inequity between HIV and TB. Regarding vaccines, seven times the amount is spent on [research for] an HIV vaccine compared to a TB vaccine." We don't need to make it a competition, but it's a matter for the TB community to step up. "The TB community needs activists to show that a TB vaccination is important."

Anton continued "It's extraordinary that we don't give people more Isoniazid. There's a lot of evidence regarding TB and HIV (showing) that people do better when we put them on Isoniazid, but people aren't taking it." We need a continuous dialogue between organisations to decide where funding is most appropriately needed. "We have people talking about Zika, but we have people dying every day from TB. In Ethiopia the AIDS association is taking funding on behalf of TB." Money is eventually getting to Tuberculosis, but an answer may be to integrate health services.

“[We've just had the] TB Pre-conference and there are some signs of change, but it is nowhere near fast enough. There have been SIX trials for an HIV vaccine, but only ONE trial for a TB vaccine. We need to think about these issues together. We need to 'leap-frog" innovation and science by making an HIV/TB think-tank. Science is the driver of development. We need to see a lot less people dying from TB. We need people to know their HIV status and use antiretroviral (ARV) treatments. If they're using ARV, then they're less likely to die from TB infection."

The panel discussion came to a conclusion, but not before Dr Anton Wozniak dropped the mic saying that after all this discussion about TB and HIV “it's important to put it into perspective that non-communicable diseases kill far more people compared to infectious diseases” - but I don’t think we have a vaccine for that yet either.

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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