The discussion generated by this, quite complex topic, was stimulating. CDC reported that a dried blood spot sample gave comparable performance to a liquid serum/plasma sample, an obvious practical benefit in much of the world. They were reporting on performance for one of the available tests trying to infer recent infection rates, the Limiting-Antigen Avidity EIA. Then 2 other presenters raised issues about the rate of miscalculation of this recently licensed  LAg test, and the evidence that Clade D infection really confuses it. Finally, Alex Welte expressed his groups reservations about relying on any one of the 5 available tests yet, saying that viral suppression, by ART or being an elite suppressor, were 2 major causes of error. Issues then discussed were whether there was any agreement about what should be defined as the cutoff time for a recent infection, whether there should be an agreed viral load limit to incorporate in an algorithm, what would be an acceptable level of "False Recent Rate", how great the lag time would be between the current recent infection rate, and Incidence calculation "look back" rate, and whether combining 2 of the assays would make results reliable. Although work on improving these current tests and algorithms is proceeding in a somewhat cooperative way, new bio marker research is also being funded hoping to find a single novel marker to overcome current limitations. Bottom line, we could probably use these tools now if we didn't need to believe they were totally accurate. Abstracts  #1005,#1006, #1007, #1008

Supplementing starters on ART containing Efavirenz and Tenofovir with 4000 iu Vit D, and oral calcium, reduced BMD loss by 50% in the first year, say ACTtG A5280. Expected elevations in both PTH and bone turnover were reduced. It at least suggests that those with low Vit D levels at initiation should be identified, and have this considered. Abstract #133

Jeffrey Johnston from CDC Atlanta presented results of highly sensitive resistance testing showing transmitted resistance in 16%, rather than the 8% previously identified by standard tests. The study population was a broad sample of new US infections 2009 to 2011. Abstract #87

Maybeof significance in future decisions about recommended PrEP and PEP.

Many presentations pushed the need to get going now with oral PrEP for it's already proven benefit, even though what we have isn't perfect, isn't used perfectly, and isn't going to be for everyone.

Interesting potential future options are suggested by macaque monkey trials investigating 3 monthly IM injections of GSK744, and vaginal rings releasing dapivirine. Both approaches seem much more likely to achieve uptake when further proven, and available. Abstracts #40LB and #41

A much anticipated late breaking presentation from London was a study looking at transmission from people with Viral Loads less than 200, who practised condomless sex. No observed transmission occurred, where on accepted transmission data 86 new infections would have been expected in the study group. BUT the science cautioned that they could still be concealing a 32% 10 year transmission risk, if related to receptive anal sex. The caution was a worst case statistic, because of the small numbers so far studied. It seems there will be a lot of explaining to patients to be done in the next few months when the study results get widely published. Researcher's suggestion, tell them "our best guess is its safe, but we can't tell you that", isn't  very useful. Abstract #153LB

Hi. I'm Ken Hazelton, a GP S100 prescriber from Orange NSW, and the grateful recipient of an ASHM scholarship to CROI,  Boston 2014. HIV is important to my daily General Practice, but not my main work.

I don't  think my blog is for anyone who is full on with HIV medicine, I think it might be of more interest and relevance to GPs who see a few patients or are interested in where HIV is going, and who might relate to the things that get my attention.

Having cleared the decks.....day 1 of CROI started with positive messages about the likelihood, sometime, of a cure for HIV. The qualification was that cures would probably start with subgroups like babies, and that there are still major barriers to eradicating the last of virus from reservoirs in lymph tissue and macrophages. The famous cure of Tim Brown, the  "Berlin patient", is a one off, involving whole body irradiation and 2 sequential stem  cell transplants from a donor with a HIV-favourable genotype. None of this is feasible for others, as fascinating as it is medically.

The other really interesting but frustrating session for me was an interactive Hepatitis C treatment decision panel. The annoying thing was the right answers from a US perspective were always Sofusbuvir and Semepravir, and that Telepravir and Bocepravir were old hat. This was on the basis of inferior effect, and much nastier side effects, but the latter two are the agents we are only now getting funded access to in Australia. More another day.