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ASHM Report Back
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.
I work as a General practitioner and Community S100 prescriber in two practices, a private GP clinic in west Hobart and the southern Tas Refugee Health center. I have recently begun to specialize in the long term management of HIV care and work in close collaboration with our Sexual Health Clinic in Hobart.
The Round table meeting made some interesting points concerning the recent instigation of PrEP in the UK and France.
Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot, France) showed that daily and on demand PrEP is cost effective for the community. More importantly it has helped take the fear of sexual activity and anxiety from a population that are over represented when it comes to mental health care issues. He felt that PrEP is still not reaching high risk groups such as young MSM, migrants and the trans population. Young MSM are a particular problem in that they often feel stigmatized about their sexuality and unwilling to engage with the medical profession. They may also be in some denial about their HIV risks and are a difficult population to ensure compliance with medication. Social media apps eg Grindr, Hornet and Planet Romeo are very important resources for HIV ,PrEP and PEP education.
PROUD and IPERGAY studies have confirmed the effectiveness of daily and intermittent/ on demand Truvada.(4 tabs). Maraviroc was not shown to be an effective PrEP agent. Current studies with TAF/FTC are promising as is injectable Cabotegravir LA. Topical drugs such as vaginal gels also have an important place. The possibility of future over the counter PrEP raised some concern by the panel who felt medical intervention is needed at some point in the PrEP pathway.
Emma Devitt from the Dean Street Clinic Soho, UK showed some impressive rates of decline in new HIV diagnoses in the last year. She felt this was due to a combination of factors their clinic offers including:
-frequent screening for HIV
-rapid ART instigation for HIV positive people
-regular STI screening and rapid Rx of STI
-use of PEP and now PrEP
A very informative and topical meeting from some incredibly dedicated and progressive doctors.
The Future of HIV Therapy
Dr Roy Gulick (Professor of Medicine and Chief of the Division of Infectious Diseases at Weill Medical College of Cornell University) from New York provided a great summary of current treatment guidelines and new developments underway with ART.
ART is now recommended to commence at any CD4 count when a patient is also ready to start. If resources are a priority then treatment should be offered first to those with a CD4 <350.
There are currently 29 approved HIV medications and up to 10 starting regimes.
5 broad mechanistic classes (NRTI, NNRTI, PI, INSTI,EI)
Recommended standard strategy is 2NRTI +(NNRTI,PI,or INSTI)
If there is multiclass failure to the 29 drugs two new entry inhibitor class drugs are showing promise.
1 Fostemsavir (oral HIV attachment inhibitor with Phase 2 results soon to be released)
2 Ibalizumab (monoclonal antibody given parenteral, binds to CD4 receptor/works as HIV entry inhibitor)
2 New classes of HIV Rx being developed:
1 HIV Maturation Inhibitors
2 HIV Capsid Inhibitors
Newer approaches to safety and tolerability in the future ART include:
Using lower doses of drug eg (EFV 400mg vs 600mg). Other studies in progress are ATV 300mg, DRV 400mg
Newer drugs eg tenofovir alafenamide(TAF). Switching TDF to TAF improved renal/bone markers
2 Drug regimes: PI/r+3TC (or FTC), PI/r+ integrase inhibitor, NNRTI +integrase inhibitor , DTG+3TC/Paddle Study(results showed VL all suppressed by 8 wks)
Less frequent dosing eg RAL daily formulation
New co formulations eg ATV/c and DRV/c
New injectable drugs RPV LA, Cabotegravir
Latte 2 study is looking at IM CAB +IM RPV with conclusions showing IM is comparable to PO and well tolerated. Phase 3 studies are evaluating IM q4wks.
Dr Gulick concluded by saying that future ART Rx will involve greater use of sub dermal implants and injections with potentials for dosing going from weekly up to every 1-3 months. Costs will radically decline and affordability improve. Convenience will also continue to improve. We have already seen the dosing levels of 20 tablets a day reduce to one a day in the last 10 years. Interestingly life expectancy in ART uses from recent studies in US, Canada and UK were showing higher figures than for the average population! Presumably regular medical intervention can be a good thing for our species!