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Day 2 of the HIV Drug Therapy Congress in Glasgow began with an excellent presentation by Dr Julio Montaner from the British Columbia Centre for Excellence in HIV/AIDS on “HIV treatment as prevention: from a research hypothesis to a new global target and beyond.” He argued that the “treatment as prevention” approach reduces morbidity, mortality and HIV transmission, and is also the most cost-effective approach to managing the HIV epidemic. Is the current UNAIDS target of 90:90:90 by 2020 feasible? This would equate to 91% of people with HIV diagnosed as HIV positive, 81% of all people with HIV being on ART, with 73% of all people with HIV being successfully virally suppressed. The current global figures fall far short of this, being 57%, 46% and 38% respectively.
Dr Montaner emphasised the importance of being alert to picking up clusters of increased incidence in specific populations quickly, with efforts to identify networks, increase contact tracing and testing, and make use of PrEP and rapid institution of treatment. He also talked about the importance of political support and mentioned previous tendencies of government in various regions to lose enthusiasm for addressing the HIV epidemic when rates appeared to be waning. He said that the piecemeal approach won’t work, and control of the HIV epidemic globally is clearly the work of a generation, not a few years.
Dr Jens Lundgren of the Rigshospitalet in Copenhagen reviewed the insights gained from the START study and the substudies related to it. This study was especially important in that it is globally applicable, being conducted over 4 years in 35 countries (250 sites), with a sample size of 4600 people, randomised to either early ART or deferred ART (until CD4 count less than 350cells/mm3). It has changed the management of HIV globally, with all subsequent guidelines advising immediate rather than delayed treatment.
Some of the unexpected results of the START trial were that in the deferred arm there were both increased rates of opportunistic infections (although CD4 counts were often in the order of 500-600) as well as increased rates of various malignancies. It had been hypothesised that the immediate treatment arm may see a reduction in CVD risk due to reduction in inflammation, but this was not the case – in fact there was no change in CVD risk. A substudy published earlier this week in the Lancet Respiratory Medicine journal showed that, if anything, the deferred arm had reduced rates of COPD. Another substudy on bone mineral density has clearly shown that early treatment leads to more accelerated decline in BMD.
Later in the day, Dr Jean-Michel Molina from Saint-Louis Hospital and the University of Paris presented a case study of the use of PrEP in a thirty year old female patient with a HIV-positive male partner. The various options for reducing transmission of HIV to the female partner (who wished to become pregnant) were discussed; the most important point being of course effective viral suppression of the male partner’s HIV, as well as condom use and also the possible addition of PrEP for the female partner as an additional precaution when she wishes to conceive. The previously-favoured approach of IVF with sperm-washing was no longer seen as the most appropriate treatment, as rates of pregnancy are much lower with this approach than with natural conception and the panel commented that an undetectable viral load was reliably associated with lack of transmission of HIV to the negative partner in studies of serodiscordant couples as well as their clinical experience of similar cases.