Levinia Crooks, CEO ASHM

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.

Levinia Crooks

Levinia Crooks

Levinia is Chief Executive Officer of Australasian Society for HIV Medicine and Co-chair of the HIV Testing Policy Expert Reference Committee. She is an Adjunct Associate Professor in Public Health and Human Biosciences at La Trobe University

This workshop is being run adjacent CROI to facilitate participation. John Mellors stressed the ongoing importance of resistance testing and subsequent drug selection so as not to render treatment scale up futile. The focus of the meeting has also shifted to being largely focused on resistance as it impacts middle and low income settings. But there were considerable references back to high income countries, particularly in relation to resistance development in the context of PrEP.

The opening presentation from Shannon Hader reviewed the current position of resistance testing in the global environment of scale-up of ART and meeting the 90:90:90 testing, treatment and viral suppression targets. NOW was seen as the time where, through a shifting focus toward quality improvement and funding high impact programs, these targets might be realised by 2030. The contracting funding climate was what was seen as driving this need to get more bang from prevention and treatment buck.

Reducing cost from not unnecessarily changing to 2nd line therapy was seen as something resistance testing could inform. Likewise making sure that individuals starting PrEP are in fact HIV negative was seen as essential and something which could be determined by earlier use of viral load.

Neil Parkin questioned the constant need for gold standard, when such aims might mean that no change is achieved. This notion was revisited throughout both days. Neil was specifically looking at the efficacy of dry blood spot viral load and resistance testing. It was recognized the DBS uses a very small sample size, thus hindering detection at lower concentrations (largely because whole blood, unlike plasma, introduces other confounding material into the sample). But this was pitched against the collection and transport benefits of DBS sample collection. In some places conventional samples cannot be collected, transported or analysed due to cost and complexity.

Suzanne Crowe provided an overview of current point of care test development for CD4 and viral load. Suzanne defined PoCT not as the technology, but the extent to which a technology could be used easily and reliably in close proximity to the patient. Like a number of other speakers, Suzanne identified the need for training. And operator proficiency as one of the largest sources of performance variation between any of the tests. The ongoing need for CD4 in the context of viral load was discussed and CD4 was seen as having a continuing place if not a rosy future.

The later discussions focused on the clinical impact transmitted resistance and the role resistance might play in the roll-out of PrEP. Interesting here was the level of discussion about clinical and preventative applications. This was great to see as previously I have witnessed a big disconnect between the science and its implementation. Dan Kuritzke questioned whether transmitted AZT resistance really meant anything in the context of AZT-free treatment regimens. Likewise there was speculation about what was driving the identification of resistant virus among 13-19 yr old MSM in large scale surveillance studies from USA. This was thought to probably be behavioural and possibly associated with amphetamines and frequency of sex and sex partners.

Clearly resistance remains very important in guiding clinical choices and in mapping transmissions. Just how these two functions can dovetail was also topical. Is it ethical to link clusters and transmissions to programs to get people on treatment? And if you have information about where infections are occurring is it ethical to not use that information? Not having HIV transmission as a crime was seen as enabling this information to be used for clinical and scientific purposes, rather than punishment. Tulio de Oliveira identified this as a facilitator of clinical and surveillance programs in South Africa.

Many of the speakers from this workshop are also presenting at CROI so no doubt much more on this topic. 

 

Tagged in: croi2015

 Link to conference summary by Tripp Gurlick now on line, an excellent overview: http://aps.mediasite.com/mediasite/Play/467fcbe8af2d44f1997197f49161d4b21d 

Trip Gulick gave a truly excellent summation of both presentations at the conference and also what can be expected in the future of HIV therapy. I strongly recommend that once the webcasts become available http://hivglasgow.org/ you watch this presentation. I cannot do it justice, but in 20 minutes six key concepts were covered and importantly the contributions they might make to improved HIV treatment by 2020:

Activity

The capacity of a drug to have physiological impact, “may be maxed out at 90%”. Conceptually the drugs might be as active or as near active as they can be. Not an area that was identified as one where great leaps can be made.

Safety and Tolerance

Both areas where a lot of movement has been made but ones identified where work can  and still is being done. Dose reduction (reported on by Di Carey from the Kirby Institute with respect to EFV) and newer formulations such as is the case with TAF (the newer formulation of Tenofovir with improve renal tolerance).

Convenience

An area in which there is likely to be continued improvement. There are now 4 single pill regimens and more will emerge. Interestingly this was an area which was questioned during the conference where convenience was seen as an area for possible trade for cost.

Affordability

This is the area of continued and emerging contention. While this presentation focused on HIV, much of the discussion at the conference on hepatitis C focused on cost. Annual ART in developing countries is approaching $139 per annum. Costs will continue to come down as new compounds are introduced.

Accessibility

Greater access to treatment earlier is the goal and a dimension in which improvement is anticipated. Identification of the undiagnosed is important as is earlier commencement of treatment. But this was framed in a context in developed countries where treatment is delayed and late diagnoses common.

Life expectancy

This was a very interesting if not unexpected analysis. Based on CHIC and D:A:Ds data life expectancy of people living with HIV has greatly increased. This may not be able to be improved much. An otherwise healthy young person, infected today might have a life expectancy in their mid 70s this compares well to averages (men 78 – women 82). If they start treatment at a CD4 above 350 this is estimated to go up to 89 years. That is considerably better than the average and naturally it relates to their engagement with the patient’s life long health system and access to other preventative and restorative health care. So again an area in which we might be maxed out as far as future benefits are concerned.

But please do look at this and the other online presentations when they become available http://hivglasgow.org/ This may be a little while as they go into post-production, but most of the presentations will be put online.

Tagged in: Glasgow2014

Tracy Swan from the Treatment Action Group in New Your provided a brief yet comprehensive over view of where we are at in relation to hepatitis C treatment access. The webcast from this session is now available on  the HIV Drug Therapy Glasgow 2014 website http://hivglasgow.org/

Or you can go to the specific talk. http://aps.mediasite.com/mediasite/Play/aae59f4f5518478ab61316c0e86530581d There is also an excellent talk at the end of this session which tries to explain the drug regulatory system, and role of generics, predominantly in Europe.  by Pauline Londeix

 

Tagged in: Glasgow2014 VH 2014

I have been party to a couple of discussion recently where there has been conjecture about the implications of an elusive undetectable viral load. Before I am attacked as a naysayer, I am not suggesting that total viral suppression is not the aim of antiviral therapy. It is and always has been. But some attention is now being directed at transient, persistent and recurrent low-level viral load. Along with virological and clinical implications, this may also have social and emotional costs for people living with HIV.

Some patients, particularly those who have been significantly pre-treated, no matter how compliant, do not achieve complete viral suppression. Others experience intermittent blips or periods of viraemia. What are the implications of these events? It is important to understand this as fully as we can because we must give people living with HIV reasoned and reasonable information; it fundamentally underpins the thinking behind approaches to cure research and, from a public health and prevention perspective, we must be careful not to alienate people.

Poster 136 (Silva, J. et.al.) from Portugal, present a retrospective observational analysis of low-level viraemia and its immunological and virological significance. It was a relatively large study of 2,161 patients 93% on ART 19% had low level viraemia 52% of whom were adherent. The mean VL was 46 (21 - 190) with an average CD4 of 665 (126 - 2,393). There was no documented virological failure, yet 51% had transient viraemia defined as one detectable VL in the study period, 40% had persistent (constantly detectable) virus and 9% had intermittent (2 occasions of detectable VL with undetectable VL in between).

Their conclusion was "in the absence of significant differences in immunological and virological outcomes and the absence of virological failure, suggests a scarce impact of low level viraemia in patient prognosis." This is qualified by suggesting that prospective and more accurate data are required. A number of oral presentations recommended treatment adherence counselling, rather than automatic switching in the presence of low level viraemia.

 

Tagged in: Glasgow2014 viraemia

I caught up with Sanjay Bhagani and asked him about his comments from day 1 about the timing of hepatitis C treatment commencement:

Could you elaborate on the safety of delaying treatment in people with advancing hepatitis C disease both in mono infection and HIV co-infection:

The question is 'When is it too late to treat hepatitis C?' In other words, when are people started on hepatitis C treatment not going to benefit; when are you are not going to prevent decompensating and needing liver transplant? This is a key area where we are going to get data over the next year or two. A number of countries are advocating the treatment of people with end-stage liver disease because of the high cost of treatment. The NHS has put in an scheme to treat 500 people with advanced disease Child-Pugh B or liver cirrhosis and I can tell you that at the Royal Free we have a number of people who are decompensating despite having started treatment. This will certainly give us an idea of when is it too late to treat people.

So when should we start?

Hepatitis C is not just a disease affecting the liver. It is a multi-system disease. It can cause renal disease, brain disease, cardio vascular disease as well as liver disease. All of these need to be considered. The concept of simply waiting until the liver is diseased might be delaying too late.

Many of these comorbidities are seen in HIV. Do they have a cumulative effect?

Certainly the data is emerging that having another virus as well as hepatitis C means that you are doubling-up on your inflammatory response. Controlling HIV is all well and good and we have been able to do that fairly effectively for some time. But if you have another virus that causes inflammation that may defeat the objective of reducing the inflammatory effect.

Thank you.

 

 

Tagged in: Glasgow2014

Perhaps foolishly I was hoping we might get more data from either the PROUD or IPERGAY studies into PrEP trials, both of which have recently offered participants in their placebo arms active drug. But we will have to wait perhaps until CROI. This morning's plenary did, however, address ARV-Based Prevention.

Stafano Vella provided an update on prevention targets and reflected on the challenges of 90:90:90. He pointed out that drug efficacy should make reaching 90% viral suppression for people on treatment the most achievable of the three. Linking the tested to treatment he saw as a significant challenge and, particularly in the global south, as a difficult goal. But the real challenge globally he saw as reaching the diagnosis of 90% of people living with HIV.

Unfortunately he did not have any magic bullet for reaching the untested and pointed out that the majority of infection occurs before people are aware they are themselves infected. No further light was shone on this issue in question time, although most of the questions did concentrate on PrEP.

Presented by Simon Collins of I-base, this discussion was a thorough recap of PrEP. There is no doubt, that if taken, PrEP offers protection from infection. Yet uptake remains low. Simon showed an interesting slide previously presented at CROI in 2013 by Bob Grant from the iPrEx group which showed the variable risk of HIV acquisition over their study. (If you have not seen it, it is slide 10 in this link www.iprexnews.com/content/croi2013/Grant-Gap-Seroconversion.pdf )

This really is important as much of the debate around PrEP seems to centre on it being a life-long issue. Clearly that is not the case, at least in iPrEx. Simon characterised PrEP as an option which men may want to access a times of particular risk. He also raised the issue of cost. Often PrEP is characterised as the use of drug which would otherwise be able to be directed to people already living with HIV and in need of treatment. There is the capacity to make more drug and generic formulations are also on the horizon. Interestingly the Simon suggested that the cost (using the Gates rate) would be less than $100 per annum, leaving room for a substantial mark-up.

Poster 199 was also mentioned. It describes two MSM on multi-year Tenofovir treatment for hepatitis B who, with high compliance and demonstrable drug on board, sero-converted to HIV following high risk exposure. Both were identified early and notwithstanding treatment both established HIV infection and their "PrEP" did not prevent the establishment of a significant viral reservoir. (Davies et.al).

There clearly remain reservations about PrEP, but it seems like the tide is turning.

 

 

Tagged in: Glasgow2014

Jonathan Shapiro has twice spoken very compellingly about the needs for simplified, clinically relevant advice to help guide decision making. In the opening debate on Sunday he argued that the difficulties of drug - drug interactions could be ameliorated by better interaction tables and desktop guidance.

He has just presented the lead review talk Resistance: What's new and on the horizon. On this occasion, while clearly indicating the continued relevance of resistance, he made a number of key observations:

  • "we now have drugs that allow us to ask patients to adhere" reflecting on the greater tolerability of current regimens
  • that resistance testing falls into a number of camps:
    transmitted resistance In this regard he predicted that there was unlikely to be a dramatic change and that transmitted drug resistance would remain between 5 and 15%
    treatment optimisation where resistance profiles are used to determine second and third line therapy; determining which NRTI to use and/or fine tuning PI selection, particularly among heavily pre-treated patients

Again he emphasised that resistance interpretation needs to be made easier. His rationale was that we are no longer in a position where drug changes are as frequent. The majority of the drugs commonly in use now are not the drugs which were being used when resistance monitoring first came into being and that as the capacity to adhere has increased, so too has the development of resistance decreased.

He urged clinicians to tell those who develop assays and their interpretation systems what they want to know. He suggested that it should be possible to provide a virtual phenotype interpretation system which would, for example, indicate what PI options were available and what additional drugs to add to optimise a salvage regimen.

He also described a setting where those with limited resources might be able to purchase a basic analysis to assist in continuation or switch strategies through to a more costly tier for complex pre-treated patients. He referred people to the Stanford database http://hivdb.stanford.edu/pages/poc.html

It is not so long ago we had discussions about using standardised resistance interpretations in Australia and trying to make reports more digestible and useful. This seems to be a recurring theme at this conference. How can we make decision making easier? The webcasts from this conference will be posted some time soon and those with an interest in resistance might be interested in viewing O33 Resistance and Tropism.

 

 

Tagged in: Glasgow2014

There has been a theme running through the conference, and I believe through the UK and Europe about where is the best place to provide HIV care. The Australian concept of the highly trained and experienced General Practitioner or Primary Care physician seems to be missing. This is interesting given the very regulated structure of general practice in the UK. But also perhaps understandable because of the existence of GUM clinics.

Yesterday morning's symposium Making Health Care Resources Count: What is the Optimal Way of Managing HIV? gave a number of perspectives. Andrew Briggs gave an interesting and informative introduction to health economics and particularly focused on the concept of driving cost down while minimising any associated reduction in health benefit. This is basically the exact opposite of introducing new drugs or approaches, which have demonstrable benefits but come with commensurate increases in cost.

This theme was continued by Nathan Clumeck who looked at task shifting to minimise cost without compromising outcomes. I think many of us are familiar with this in the developing country setting. But diminishing health budgets are making the discussion of these issues more prominent in the developed setting. WHO has recently published approaches to task shifting in resource limited settings.

Jens Lungren introduced an additional concept to the cost benefit analysis, that of the additional contributory benefit of prevention and reduced transmission, gained by achieving durable suppressive therapy. In his cost benefit analysis a slightly lower benefit for some patients, might be traded for greater population benefit. For example having more people on adequate suppressive therapy, might have a better cost profile than less people on very high cost suppressive therapy, and some people getting no therapy at all.

Alain Volny-Anne presented an interesting patients' perspective reflecting that decentralised care and community care could mean that people living with HIV now needed to access multiple care providers if they were no longer having all their care needs provided by a specialist HIV facility. He referred to this as the "go away" trend. One of the Australian HIV Community S100 prescribers indicated that in Australia she would be able to provide the majority of that care in the general practice setting.

The outcomes from this session were that prevention is cheaper than treatment, no matter how treatment is delivered. Tasks can be shifted provided that there is adequate training, with supervision and support when required. Nathan Clumeck described a model which involved generalists, physicians assistants, nurses and peers in the delivery of routine care, with second and third line care being restricted to specialist physicians.

Additional Abstracts

Two additional abstracts were presented in this symposium. They related to regimen changes as a way of reducing drug costs in the UK. It has to be recognised that there were abstracts added to the symposium and not papers developed for the symposium. They both suggested considerable cost reductions:

  • Hill by switching from brand name co-formulations to generic single drugs multi-pill regimens, and
  • Walker by switching from triple-therapy to PI monotherapy

Questions and comments from the floor and subsequent discussions were mixed about the point of even considering these options. It was pointed out that the introduction of generics may result in people having their regimen dictated by their capacity to pay as well as by purchasing and discounting arrangements used by Foundation Trusts negotiating prices.

Two posters on the related themes of where best to provide care:

P139 A comparison or routine and targeted testing strategies Perez et. al. from Spain, Found that routine testing was ALWAYS better in primary care. Targeted testing was lower than routine, testing only 50% of the population. But the best result were found in routine targeted testing in Primary Care.

P160 Late diagnosis among our aging HIV population Mensforth et. al. UK. Found that 27 people over 50 with a HIV indicator condition were not tested for HIV in acute medical unit.

 

 

The Conference started yesterday and I attended a very interesting workshop on the ongoing relevance of Drug Drug Interactions. The debate, which found ongoing interested and need for attention to drug drug interactions, gave way to three very important case disucssions about DDIs in the context of coinfection and comorbidities.

Sanjay Bhagani presented on the HIV/HCV coinfected patient. While a complex case it was illustrative of some of the issues in managing not just coinfected, but also HCV mono-infected patients and just how long it is safe to delay the commencement of treatment and how much DAAs can rescue patients with advanced liver disease. I am going to try and talk to him in more detail about this during the conference.

Marta Boffito presented on recreational drug interactions with HIV therapy and suggested that some presumed interactions could simply be poor dosing or understanding of the variability of rereational drugs on the part of the patient.

Lastly Kelly Dooley, reporting on TB HIV coinfection raised the issue of whether to treat TB before starting HIV Therapy. Cautioning that the emergence of multi drug and XDRTB suggests treating HIV at the same time. Fortunately we do not see a lot of TB in Australia, but with changing epidemiology this may become more important.

Levinia

Tagged in: Glasgow2014


Almost 200 delegates were supported through the Australia Awards Fellowship Program (and a small number of other donors) to attend an ASHM Leadership Course before and after the AIDS2014 Conference.

Participants were also provided with mentoring throughout the Conference and a dedicated mentoring space where they could meet with each other, hold impromptu meetings and hook up with their mentors either individually or in groups.

Most participants attended a short course before the conference as well and some are attending short courses now. They cover a range of topics from HIV Medicine, Community Advocacy, Research and Laboratory skills.

The two days before the conference were quite inspirational and gave participants an opportunity to experience how leaders develop their skills and nurture leadership values within their organisations and communities. The MH17 disaster gave participants an insight into how Leaders tried to make sense of such a thing and also provided an opportunity for immediate and subsequent discussion of this issue.

On Saturday, following the conference participants took learnings from the conference and their short courses and had an opportunity for hands on learning in a range of about 20 skills building workshops which spanned issues such as results based planning and management, through to setting up a face book page, quality improvement, preparing a manuscript for publication, harm reduction, improving abstract writing skills, research skills and techniques and developing a social media presence.

Sunday was the time for reflection and planning. Particularly, planning to make sure that the group develops into a network and continues its networking and mentoring once people return home. A full report will be compiled over the next month and the group will continue to communicate through the ASHM Partnership Platform which facilitates ongoing mentoring.

ASHM and collaborators from AFAO, ARCSHS, Burnet, Kirby, Monash, Sydney University and NRL came together to enhance the participation of these regional delegates.  We did this by negotiating with the Department of Foreign Affairs and Trade to prioritise round 14 of the AAF program to Conference related activities. Delegates were from 20 countries from Asia, Pacific and African regions.




Tagged in: AIDS 2014 IAS2014

 

Hong-Ha Troung, presented more data from San Francisco characterising new HIV infections. STIs remain a significant cofactor in new infections and 57% of recent infections are related to clusters. The definition of cluster was quite restrictive and did not include sequential infections so perhaps underestimates related infections. Important for the Australian setting was the very strong take home message that STI testing, treatment and prevention messages must become decoupled from HIV prevention activities. Abstract #37

Alison Rodgers presented data from UCL on condomless sex. This work goes to the heart of what we are seeking which is greater understanding of the extent of the prevention benefit of treatment. The data looked impressive with no transmissions reported, in any of the arms where partners had a VL <200 copies. But Rodgers was eager to point out that the confidence levels meant that this did not translate to 100% protection and that this was particularly the case with the MSM group. A factor which makes answering this question difficult is that most studies are looking at condom use AND treatment. So it was useful to see an analysis of condomless sex. Abstract #153LB

The importance of adherence to PrEP was highlighted by a number of speakers throughout the day. A number of speakers in the Prevention and Epidemiology session Evolving Trends (Session O-3) made reference to poor performance being a result of lack of adherence rather than failure of prophylaxis. And many speakers reflected on this emphasising the need for a good understanding of the social and other pressures on study participants.

PrEP is getting attention from both developing and developed country settings. It is sobering that so few studies are actually underway. Nelly Mugo, Abstract #62, found that only 1 of 10 studies had actually started, yet drugs for use as PrEP have been licensed for a considerable time. 

 

Tagged in: CROI2014 PREP

There has been a considerable level of optimism at the International Network of Hepatitis in Substance Users conference in Munich today. There is a blossoming of new drugs to treat hepatitis C and they appear very effective over shorter durations than conventional therapy. The new DAA, those currently listed and those on the horizon or still in trial are competing for >90% sustained virological responses with some claiming  up to 100% in one of more genotypes. A number of presentations demonstrated that with support substance users can manage and complete treatment.

But the undercurrent to this meeting has been the issue of cost. Europe is reeling from the financial crisis and austerity measures. The cost of these new compounds is seen as prohibitive in developed economies, let alone middle and developing country settings. We have seen this in Australia with the listing of the first two DAAs. How we approach this issue is not clear, but it is likely that patents, trade agreements and intellectual property issues are likely to come under increasing scrutiny.

Restricting access to HCV treatment in people who use drugs is not supported by the science presented at this meeting and treatment is effective and achievable at a similar rate to that among non-drug users. The concept of treatment as prevention was raised by Natasha Martin from the University of Bristol and even modest treatment uptake has prevention benefits in her modelling. Michel Kazatchkine, reviewed the findings of the Global Commission on Drug Policy which has highlighted the futility of the war on drugs and its negative effects on health. The Commission has recently recommended harm reduction and treatment and Michel called for investment in health rather than the war on drugs as we move toward the 2016 UNGASS.

Treatment as prevention in hepatitis C has not really received much consideration yet in Australia. It was debated here and is emerging as an important concept in durable HCV management. As in HIV, it seems we must be exploring the role that treatment will have in preventing new HCV transmission. The review of the hepatitis C strategy provides an opportunity for exploring this issue further and modelling of the prevention effects of treatment should be included in the new National Hepatitis C Strategy.

Tagged in: IAS2013 INHSU

this is a preliminary announcement just to let you know we will commence the reportback on the conference from the end of the closing ceremony. posts will appear once they are uploaded and this will largely be at the discression of the writers and the time they have available.

there are a number of preliminary meetings and we hope also to provide some reports back from those as well as satellites occuring throughout the week of the confernece.

ashm may also send specific alerts to members and affiliates if there is significant material being uploaded in their areas of interest.

i hope you find this service useful.

Tagged in: AIDS 2012

People will recall that iPrEx investigators questioned whether adherance to prophylaxis was the cause for transmissions in the active arm of the iPrEx study. Late Breaker #31LB reports on this. They compare plasma drug levels to those in an unrelated observed therapy trial STRAND with doing at 2, 4 and 7 days per week. The active arm had an overall preventative effect of 90% but when broken down by similarity to the STRAND data they found 76% efficacy at 2 day per week dosing levels, 96% at 4 and 99% at daily.

You will find the paper on the CROI Website, as well as the Oral Abstract session from 6 March 2012 in the 10am session.

Tagged in: CROI2012 PREP

Session 35: New Frontiers in HIV Testing

Bernie Branson from CDC gave a fabulous talk on HIV Diagnosis: New Tests and New Algorithms. Those of us involved in any of the current disucssion about testing really should view this whole talk. It should be up on the CROI Website shortly.

His slides are most informative, particulaly a graph which plots back from when a Western Blot would detect HIV infection, indicating how many days before a Western Blot 2nd, 3rd and 4th generation tests can identify infection.

He describes a number of the initiatives to increase testing and is encouraging the adoption of the recently updated algorithm for HIV testing in the laboratory. The algorithm and supporting evidence is published in the December 2011 issue of The Journal of Clinical Virology. He also disucsses mechanisms to get conventional testing more available and review a number of Point of Care Tests.

He raises the issue of the implications of new tests including home based tests. He is cautious about some of the tests failing to identify new sero-conversions and makes reference to findings that men are reporting they would use test results to assist them in sero-sorting (so having the wrong result could have significant implications).

It is a great talk I suggest you view it and share it with your colleagues.

The second talk in the symposium is by Blayne Cutler, from New York City Health and Mental Hygiene. She reviews a number of strategies which have been put in place in the Bronx and more recently Brooklyn to increase HIV testing. She approaches this from the point of who has never tested and their attempts to reverse this. 60% of people have never tested and of these the majority are adult men. She also examines some strategies to move testing into the community and get programs supported at implementation level.

These two talks have been hugely informative.

See the session on CROI website

Tagged in: CROI2012

People who know me will know that this is a particular interest of mine. There are a number of posters focusing on the role of very early infection in onward transmission of HIV and it has been mentioned by a number of speakers.You can access the poster abstracts from the CROI Website but I will give you a few points about particularly interesting ones here.

Poster 1107 A French analysis of genotypic profiles for 987 patients between 1999 and 2010. Identified manyclustered transmission ranging up to 24 months, Often associated with younger MSM, while 54% were in Paris, 19 or 56 were in distant French regions and 13 of the 19 involved at least one person from Paris. Their conclusion is that primary HIV infection is a significant source of onward transmission especially in MSM and contributed to regional as well as Paris-base infections.

Poster 557 Acute infection would be missed in a small but important number of cases using Architect HIV Ab+ p24 Combo. 5 of 14 early not detected. Interestingly this 5 were in ramping up fase and had distinguishably different HIV dynamics. The do an analysis of cost on the basis of onward infections and argue the case for HIV NAAT.

Poster 552 Chance of transmission in early HIV infection 13 x higher via UAI. In a San Francisco sample early is considered less than 100 days. Gay men with acute infection comprise 2% of the infeted population (49% untreated and 49% on treatment) but account for 22% of new infections.

Tagged in: CROI2012

Wafaa El-Sadr presented a comprehensive over view of treatment as prevention strategies and studies. the data came from both African and US studies. Importantly she indicated that all aspects of a program were important, increasing test, increasing engagement with care, lowering the CD4 count at which treatment is initiated and treatment ahderance. She estimated that of the approximate 1,200,000 Americans living with HIV approximately 850,000 were not successfully on treatment. This theme is maintained in the posters, where an interesting poster from New Jersey #1075 by Ruthie Birger provides a hierarchy of interventions necessary to impact community transmission.  

Wafer's talk is now available from the CROI website and it is well worth a viewing, particularly for anyone thinking about test and treat. It was very suprising for me to really get a handle on just how poor coverage of treatment is in parts of the USA, given there is so much research which comes from here.

 

Tagged in: CROI2012

Quarraisha and Salim Abdool Karim opened with the N'Galy- Mann lecture. Their talks chronicled 20+ years of HIV research and epidemiology in Africa.
The CAPRISA 004 study into tenofavir gel used vaginally to prevent transmission was discussed. Salim gave a particularly interesting review of the analyses they did into why the results were not better. Adherence of >80% was associated with better protection, but concurrent genital inflamation, resulting in increased cytokine involvement in the vaginal region, was associated with a 14 times greater risk of HIV Infection. The whole presentation which went into a number of other issues will be avaiable on the CROI site soon, but the take home message from this was the importance of STI screening and the impact that STI s can have on priming HIV binding sites.

Tagged in: AIDS 2012 CROI2012

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