Wednesday 23rd July 2014
After a long wait to see Bill Clinton address a packed audience to encourage us to continue to implement the goals of the WHO (and who addressed the gathering as a ‘movement’ rather than a conference), sitting in the special session on antiretroviral management in 2014—an interactive case-based discussion with several prominent HIV and hepatitis specialists—almost seemed ‘easy’ rather than trying to solve the complex public health problems of the developing world.
At the completion of the session, however, we were brought back to reality by a sobering statement from an African doctor who did ask that perhaps the next discussions could take into account the limited antiretroviral options in developing countries with likely scenarios from those regions, hitting home to me just how lucky we are in the Australian treatment environment to have so many choices.
It was also pleasing to see that when asked about simplification regimens for simplicity sake that several panelists were of the opinion that ‘if it isn’t broken, don’t fix it’ as we may switch patients to a less tolerable regimen with poorer adherence and without past records we may run the risk of archived resistance. The concepts of a ‘lateral switch’, where a patient has been naïve to treatment and there is minimal risk to switch versus a ‘vertical switch’ where we may not know of past suppression or resistance profiles was also discussed.
Links to the various guidelines can be found below:
1. ASHM 2014 Antiretroviral guidelines
2. US DHHS Adults and adolescents antiretroviral guidelines
3. American Society for the study of liver disease and the Infectious Diseases society of America: guidelines for hepatitis C treatment
Two very interesting studies from the Kirby were also presented this afternoon.
Firstly, Ben Bavington presented results from the Opposites Attract study looking at behavioural risk compensation amongst couples in the study. ‘Behavioural risk compensation’ being the concept where there may be reduction in condom use due to perceived protection from antiretroviral medications.
Approximately 77% of the HIV negative partners perceived their HIV positive partners viral load was undetectable, which was largely in accordance with pathology results. This did seem to correlate with engagement in condomless sex with approximately 73% HIV negative partners reporting condomless sex (CLS) when they perceived their partner’s viral load to be undetectable and thus demonstrating risk compensation within this group. Amongst the HIV positive partners, however, approximately 90% were taking antiretroviral therapy so perhaps this gave a protective effect.
In a separate session, Andrew Grulich presented on results of the SPANC study. This is an interesting area in that there is a 30-50% prevalence of high-grade anal lesions (HSIL) in gay men.
Treatment is difficult with recurrence rates of 50% at 1 year with grade 3-4 side effects. Progression to cancer is also 1/400 per year in HIV positive men and 1/4000 per year in HIV negative men. Of men recruited into the study they found that 1 in 6 men will develop HSIL per year (16/100 person years) with a clearance of 42/100 person years over 12 months.
HIV positive men were more likely to have HSIL but there was no correlation with age. HSIL was also very uncommon in men without chronic HPV infection. Pleasingly, with the high clearance rates, he concluded that if HSIL is identified that it does not necessarily require treatment and could be observed.