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.

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Greetings from Washington DC. Nice to be back. I used to live here and went to George Washington University as an undergraduate. I couldn’t understand why all the guys at University wore pink cashmere jumpers and tartan trousers until a friend from Australia sent me a book on ‘Preppies’.

Today we had a retrospective symposium on SMART: “Five Years after the SMART study, a Paradigm-shifting Trial” (SUSA56)

Some of the speakers’ points are outlined below

Tony Fauci opened the Symposium noting that SMART one of the most influential trials in HIV medicine, that it helped us understand the importance of chronic immune activation and coagulation in HIV disease and, finally, that it was the result of major collaborative efforts.

Wafaa El-Sadr reflected on HIV Treatment Research in 2002
She reflected on the background to the SMART study: the idea was conceived in her apartment in New York city one evening with Jim Neaton, Fred Gordin and Birgit Grund.

Wafaa noted:

  • The impact of SMART was to immediately change guidelines such that treatment interruptions were not recommended at a guideline level
    - Objective evidence of SMART’s impact upon treatment patterns comes from an analysis of the Royal free database: after SMART the percentage of people using intermittent ART decreased from 5-6% to 2%-3%.
  • A paradigm shift occurred as a result of SMART vis-a-vis a greater understanding of the pathogenesis of HIV disease.
  • With all the bio specimens that were collected in SMART it created the opportunity to engage with non-HIV doctors who became interested and utilized the samples from SMART in collaboration with SMART investigators => excellent synergies from working with people outside of the HIV field

Wafaa’s final slide noted

  • SMART challenged the status quo
  • Getting an unexpected answer to a question is often more profound than getting the expected answer
  • Seeking definitive answers to tough questions is not easy, requires patience and may be costly but is well worth it
  • Other tough questions of the hour remain that will have to be answered

Andrew Wilson addressed HIV Treatment Research Post SMART
He noted:

  • That SMART was the first trial that used serious non-AIDS events as a major trial endpoint
  • That 92% of all deaths in SMART were serious non-AIDS events
  • Clinical event risk at high CD4 count range are nearly all related to non-AIDS conditions - these events were not being collected in most HIV cohort studies at the time
  • The key question is what is the ongoing excess risk of morbidity due to HIV in people with successful viral suppress on compared to HIV negative controls ART

Jens Lundgren addressed why the START trial is necessary and how it stands on the shoulders of SMART
He posited that one must consider the case that START may show early ART is harmful and he invoked the physician’s creed: Primum non nocere (first do no harm).

This argument runs as follows:

  • Morbidly and mortality in early HIV in young persons are LOW
  • ART may adversely effect a variety of organ functions
  • If this scenario turns out to be correct we will know whether early ART is harmful within 3 years
  • Jens also noted that only 3 RCTs had addressed early versus deferred ART: The Haiti trial (NEJM 2010), the SMART subgroup (JID 2008) and HPTN 052 (NEHM 2011) but none of these used the same CD4 criteria as START
  • He also noted that 4 observational studies had addressed early versus deferred ART: When to start, NA ACCORD, Causal collaboration and CASCADE
    - However using the GRADE classification (see www.gradeworkinggroup.org) these studies would be graded as C whereupon a score of A is best

It was an excellent retrospective.

Tagged in: AIDS 2012
Reach for the stars, keep your feet on the ground

... So said the former American president Roosevelt. The opening ceremony is going well. It is a hot Washington day.

It is now feasible once again for this conference to be held in the USA after more than two decades. The recent policy  change in allowing international openly positive HIV people to be welcomed in the USA is an important and much needed step forward.
 
The AIDS 2012 theme is "Turning the Tide Together".

The platform speakers - scientists, community leaders, faith based leaders, celebrities and importantly those infected and affected share much enthusiasm and encouragement as well as messages of hope. There is a repeated call that ongoing political and  community responses and resources are needed to allow science to continue to increase the knowledge needed to deliver progress in searching for cures and vaccines, and to continue to make available the essential education, prevention and treatment services. For me, the image of hope that most resonates is the image of the AIDS quilt panel - "The Last One". See attachment. I saw this yesterday at a preconference event.

Platform speakers included a 24 year old HIV infected woman from Zimbabwe, the Washington gay men's choir, two recently imprisoned Iranian physicians, an African - American pastor, HIV program leaders, the president of the World Bank, an actress and the UNAIDS director with more to follow...

Tagged in: AIDS 2012
MSMGF Pre-conference: stigma and access to prevention

In the US, 60% of new HIV infections are among the 2-5% of adult men who are gay, bisexual or other men who have sex with men (MSM), and rates of HIV diagnosis among MSM are increasing in many countries. It therefore seemed fitting that my warm-up to AIDS 2012 involved attending a pre-conference hosted by the MSM Global Forum. The early plenary speakers, including US Congresswoman Barbara Lee, former Australian High Court judge Michael Kirby and Dr Kevin Fenton (US CDC), highlighted the challenge of delivering effective HIV prevention and treatment when MSM in many countries are faced with hostile laws, violence and homophobia. The rights of MSM and transgender people are often precarious or non-existent and work to counter prejudice and protect these populations is vital but bruising work. 

 

It’s anticipated that much of the debate at AIDS 2012 will relate to developments in HIV prevention science, notably the preventative benefits of antiretroviral drugs when HIV-positive people are treated effectively (treatment as prevention) or when HIV-negative people take antiretrovirals (pre-exposure prophylaxis or PrEP). Kevin Fenton in particular spoke about how treatment as prevention and PrEP, when combined with existing strategies (such as condoms, treating STIs and so on), could dramatically reduce the sexual transmission of HIV among MSM, if targeted and implemented well. However, many in the field are uncertain about how to integrate, target, deliver and evaluate these strategies. 

 

A session on new prevention strategies featured Dr Robert Grant, lead investigator of the iPrEx trial of PrEP. Dr Grant echoed Kevin Fenton’s comments about implementation, admitting that despite the recent FDA approval of Truvada for use as PrEP, debate continues in the US about how best to target PrEP to MSM, how to facilitate access to those who will benefit most, and how to support those taking PrEP so that protection is maintained (PrEP’s efficacy is much higher among people who maintain a detectable level of the drug). Dr Grant raised some interesting issues about promoting effective PrEP use. He said that potential users should be told the realities of taking PrEP, rather than focusing on hypothetical risks. He said that potential users should be told that PrEP is highly effective if drug levels are maintained, but it is not as easy to take as you might think e.g. remembering to take pills, having to have regular HIV tests. Dr Grant argued against ‘intensive counselling’ or banning people from PrEP who report illicit drug use, saying this unnecessarily limits access and is not justified by the experience in trials. 

 

Dr Grant argued that MSM who have unprotected anal sex are generally still motivated to protect themselves from HIV and PrEP can help them. This point was echoed by Bruno Spire (from INSERM in France), saying it had been a motivation to set up the IPERGAY trial of intermittent PrEP dosing, currently enrolling gay men in France. In response to questions about how to justify the cost of PrEP, Dr Grant made the point that PrEP is cost-effective when you think of it as a short-term use of antiretrovirals to prevent HIV infection, life-long treatment and a higher risk of comorbid conditions. It will be interesting to see if this pragmatism about PrEP will be taken up in Australia.

Tagged in: AIDS 2012 PREP

this is a preliminary announcement just to let you know we will commence the reportback on the conference from the end of the closing ceremony. posts will appear once they are uploaded and this will largely be at the discression of the writers and the time they have available.

there are a number of preliminary meetings and we hope also to provide some reports back from those as well as satellites occuring throughout the week of the confernece.

ashm may also send specific alerts to members and affiliates if there is significant material being uploaded in their areas of interest.

i hope you find this service useful.

Tagged in: AIDS 2012

Quarraisha and Salim Abdool Karim opened with the N'Galy- Mann lecture. Their talks chronicled 20+ years of HIV research and epidemiology in Africa.
The CAPRISA 004 study into tenofavir gel used vaginally to prevent transmission was discussed. Salim gave a particularly interesting review of the analyses they did into why the results were not better. Adherence of >80% was associated with better protection, but concurrent genital inflamation, resulting in increased cytokine involvement in the vaginal region, was associated with a 14 times greater risk of HIV Infection. The whole presentation which went into a number of other issues will be avaiable on the CROI site soon, but the take home message from this was the importance of STI screening and the impact that STI s can have on priming HIV binding sites.

Tagged in: AIDS 2012 CROI2012

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