A very brief blog on Hep B treatment and new agents presented by Jürgen Rockstroh

TAF works for Hep B

Here's the data

Can we cure Hep B like Hep C?

Names in black are in the pipeline

A picture paints a thousand words - Dual Drug Therapy.. a blog in pictures (a Plog?)

This is the history of therapies in HIV

3 drugs work, why are we going back to 2? It's not like we haven't done it before with poor results

Why do we even need a 2 drug regimen

Some definitely don't work - don't try these at home, but some bear looking at again

Eg.

and

Hmmm

Think about this

Is DTG the deal breaker?

PADDLE - the proof of concept

The follow on is GEMINI 1 and 2, current Phase 3 trials - data to follow........

Watch this space?

Day 1 of APACC 2017

Other bloggers have written eloquently on sessions on day 1 at this meeting so I thought I might report on my impressions on the 'first 24 hours' of APACC 2017.

At conferences such as these, i am constantly reminded how lucky I am to be practising HIV Medicine in Australia, with universal healthcare and the PBS system for access to medications.

Australian clinicians and leaders in HIV Medicine (both in policy, research and mentoring) have been providing significant, and exemplary, leadership in the Asia Pacific region. This is certainly seen in the high regard and respect that is extended to Australian clinicians present at APACC. I had not realised this, but now wonder if there has been any interchange of knowledge at the 'grassroots' level of HIV care. I believe that we have a fantastic model of primary care management of HIV in Australia, and wonder if that is translatable to our regional neighbours. This may be an area for further exploration in the future, esp. as the RACGP already has associations with primary care groups in Malaysia and Hong Kong 

Many Asia Pacific countries can be considered 'resource limited' in terms of support from their government/health agencies and limited access to medications eg. China's public health clinicians do not have access to INSTI's or ANY STR's. The Chinese National Free Antiretroviral Treatment Program only has access to 3TC, AZT, d4T, ddI, NVP, TDF and EFV. Most recently LPV/r was added as the 2nd line option. Contrast this to Australian clinicians who are mostly proactively getting rid of Atripla from our medical armamentarium, switching to TAF containing STRs and have access to INSTI's.

Chemsex is also an issue in Hong Kong, as it is in Australia. A poster presentation which surveyed 30 HIV positive men diagnosed recently, revealed that all had used methamphetamine in the context of sex, and 73% of participants fulfilled DSM-IV criteria for stimulant dependence syndrome.

There is a ART backbone 'turf war' going on in the region due to the rise of the concept of dual drug therapy in HIV. In their industry-sponsored symposia, arguments were put forth for maintaining a 3-drug backbone esp with TAF which is not currently in widespread use in the region vs. moving to a 2-drug regimen for naive or switch therapies which has appeal to the region ie less cost. 

This stream covered quite a range of issues in regards to PrEP and it's use.

Dr Zablotska told us that community surveys show informal prep is currently being used in AustraliaPrEP was being accessed were through state based PrEP demonstration projects or through self importation. It was important to know the likely eligibility and demand for PrEP in the community. Based on the highest risk group ie MSM and using national statistics, self reported data and guidelines - conservatively it was estimated that eligibility and demand for PrEP ranged from 2500 to 6000 cases.

Dr John de Wit presented data on the change in sexual behaviours and risk reduction in men who are on PrEP. Using baseline and 3 month questionnaires from VicPREP - nothing changed in subjects with regular partners, in either frequency of sex or risk reduction practices. In subjects with casual partners - there was no change either BUT there is a moderate reduction in condom use in casual partners, specifically an increase in 'never used a condom' and a decrease in 'most of the time' in the last 3 months.

This was definitely a difference between trials/extension projects vs demo projects. It is possible that there was a selective change in risk reduction practices, based on informed decision making to balance risk and pleasure. A focus on 'real world' use of PrEP would have to be on sustained education and support on sexual risk reduction strategies, including condom use. This would especially be important for other STIs. This was my take home message from these sessions.

Dr de Wit then spoke about the early experience of men using PrEP in the VicPREP demonstration project. Although 53.9% of subjects reported missing ANY prep doses, the median number of doses missed was 1 dose. This didn't alter the effectiveness of PrEP. The main reason? Forgetfulness!

Presented by Dr Phillip Read, Sexual Health Physician and the Acting Director of the Kirketon Road Centre in Sydney’s Kings Cross who spoke about the rising rates of Syphilis and co- infection in HIV+ve men. There are increasing rates of syphilis notifications in the MSM cohort, with more than 50% of notifications in this group. In Canada, there is a 300x increase in rates of syphilis associated with HIV infection. In OECD countries, there are increases evident in the male to female ratio of syphilis infections. 

What a privilege to attend this forum which featured amongst others Dr Robert Grant, named one of Time magazine’s most influential people in 2012 for being the father of “treatment as prevention.” Dr Grant highlighted the observation that PrEP use in San Francisco had reached a positive tipping point in the last few years, with increasing use of PrEP. How have they come to this point?

It's been driven by:
1) PrEP research and demonstration projects being run in San Francisco
2) The FDA approval for Truvada use in PrEP, and
3) Word of mouth and the use of social media

Dr Grant also reiterated that by using an intention to treat analysis, PrEP is efficacious - the analysis shows that in order to prevent 1 HIV infection, 13 to 18 people were required to be treated. The recommendation for PrEP is for daily dosing although the data shows that if users were taking PrEP 4 times or more per week, the benefits were maximised. Daily dosing provides for a high level of protection and is forgiving of the occasional missed dose. The exciting takeaway message I took was that currently, there are Phase 2 Trials in long acting injectable PrEP, which may come to fruition around 2020.

Dr Darren Russell spoke about PrEP in Australia and the current 'lay of the land'. Importantly, he announced that the HIV Foundation Queensland was in planning to roll out an affordable access program for low-income individuals via the Foundation, to counter the social and ethical inequities of access to PrEP in Queensland. Dr Russell also 'hypothesised' that Truvada for PrEP may obtain TGA approval in the first quarter of 2016 and hopefully PBS approval in the latter half of 2017 (all going well). Watch this space!

Most importantly, this forum highlighted the social science and personal impacts of PrEP - it's ability to mitigate the fear of HIV, the empowerment of users, the circumvention of condom difficulties to prevent HIV infection. We heard both from Chris Williams an early adopter and PrEP advocate and Dr Fiona Bisshop, a PrEP prescriber at Holdsworth House Medical Brisbane.

The final word? If you are not PrEP'd for the future, you better get with the program.