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Greetings from the 9th IAS Conference on HIV Science in Paris, France. As usual the content is broad, but (as the new branding signals) science dominates the agenda. On this occasion there is no great breakthrough or advance that might electrify the event and set tongues wagging.
From a global access to care point of view it is clear that funding is at best flat-lining (and this has been the case for the past 7 years) and in some cases falling as we move well beyond the Millennium Development Goals and firmly into the era of the Sustainable Development Goals.
It seems unlikely that the Trump administration will increase U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding and most likely will withdraw funding during this Presidency. According to UNAIDS. 19.5 million people are now receiving ART around the world. However it is estimated that 40% of all those infected are unaware of their HIV-status and that for every 1 person dying from AIDS every year 2 become HIV-infected. Thus, while the UNAIDS 90-90-90 goals are commendable, we are a long way from getting even close to achieving them. In this context the goals are in danger of being perceived as an impossible dream.
Such musings inevitably focus attention on the critical need for an effective vaccine to truly augment efforts to eradicate the HIV pandemic. Unfortunately there is little news on this front and we need to be realistic and understand that this may be a task beyond us given our current understanding of HIV pathogenesis. This is also the case with the cure, which despite intensive investigation over the past decade has little to show for all the effort. As with the HIV vaccine, a true advance will most likely come from a profound and unpredictable (and unfundable) paradigm shift in our understanding of HIV pathogenesis and immune protection. Let’s hope that occurs in our lifetime, but if I were a betting man…
Better news comes from the fields of therapeutics and PrEP
PrEP rollout is going well but is to a large extent restricted to those countries in which the research has been conducted – France, USA and Australia. Efforts are being made to introduce PrEP into Africa, but a major drawback is the lack of efficacy often seen in younger women (16-24 yo) with oral TDF/FTC. This may be overcome with the use of injectable long acting ART agents like cabotegravir and rilpivirine, and also possibly intra-vaginal rings containing ART (e.g. Doravirine). These rings could also be impregnated with other pharmaceuticals (e.g. oral contraception, anti HSV products, antimicrobials). We await the science.
This conference also saw the presentation of the phase 2b RCT of 2 drug maintenance of initial triple therapy induced virological suppression with long acting injectable cabotegravir and rilpivirine. Over 2 years in the once monthly injection group no virological failures were observed. This once monthly strategy is now enrolling participants in pivotal phase 3 RCTs. Joe Eron (UNC, USA) who presented the data at the conference said that the 2-monthly strategy is also still under active consideration. The result was reported by a few media outlets including the BBC.
See Injections 'next revolution' in HIV - study by James Gallagher:
The conference was also the venue for the public presentation of Phase 3 RCTs of Gilead’s unboosted once daily InSTI ‘Bictegravir’ versus Dolutegravir. The results of 2 Phase 3 placebo-controlled, double-blinded RCTs were presented; one with a backbone of TAF/FTC in both arms and one with BIC/F/TAF versus DTG/ABC/3TC. Non-inferiority was demonstrated in both cases with good tolerability across all groups. Importantly, no resistance was seen in the rare virological failures in both studies, consistent with what we have seen with DTG to date in trials and clinical practice. It is expected that the BIC/F/TAF fixed dose combination product will be licensed in the USA by Q4 2017 and most likely be listed on the PBS by Q3 2018 in Australia.