Excessive intellectual property protections for HIV  treatments:  the momentum  for reform

What a clear and informative presentation  Charles Chauvel , Team leader, Inclusive Political  Processes, Bureau for Policy and Programme Support, United Nations Development Programme, New York, USA delivered towards  the last end of Day One of the 2015Australasian  .HIV and AIDS conference

The ethics of patents has long troubled most health practitioners, and none more so, than those wanting  affordable  access to antiretrovirals  at  rates that will not deter people receiving,  needing or wanting HIV  treatment or prophylaxis.

Charles outlined that disease and poor health remain major barriers to sustainable development in  many countries. HIV and malaria and viral  hepatitis  continue to  kill  more that 5  million  people every  year and  most of the deaths occur in  low or middle income families. Even in rich countries, drugs like sofosbuvir are largely unaffordable to all the citizens. He also outlined that there are also non patent factors affecting access to medicines.

 Charles outlined that a patent is a type of intellectual property. It is a social contract between an inventor and society.  It gives the inventor the temporary and exclusive right to make use, export or market an invention in the country where the invention is patented.

 Patents affect access by creating protection on existing drugs, and the patents give exclusive control to  licence, manufacture and distribute the product. It also influences the kind of innovation which in undertaken in  the first  place.

 The Agreement on Trade – related Aspect of  Intellectual Property Rights was agreed to  in  1994 and came into  force in  1995. There was also another agreement setting minimum standards of IP protection and enforcement for countries to follow.

TRIPS Agreement Objectives (Article 7) states” The protection and enforcement of IPRs should contribute to the promotion  of technological innovation  and to  the transfer and dissemination of technological knowledge and in a manner conducive to social and economic welfare, and to the balance of rights and obligations.”

TRIPS Agreement  Principle (Article 8) indicate “ Members ……(should) adopt  measures necessary to  protect public health  and  nutrition, and to  promote the public interest in sectors of vital  importance to  their socio- economic and technological development, ………”  But the rights of the inventor Should also be protected.

Furthermore, there is IP “creep” and practices and measures since the original  Agreement have consolidated the Agreement.

Charles outlined the high  costs of ARVs. He said second  generation  ARVs cost 3.4  times more than  first  generation drugs.  Third generation ARVs cost 23.4  more than  the first generation  ARVs. He indicated India make over 80% of ARVs and their legislation  has enshrined the TRIPS agreement.

It also  seems TRIPS may be  further broadened and the term of patent protection  extended and create barriers to  medicines registration by “linking” IP to  marketing requirements.

The  Human Rights Commission  called for reform  in  2009 . It said “  …. Take into account the right o f everyone to the enjoyment of the highest attainable standard of  physical and mental health …..and supports public  health policies that  promote broad access to safe,  effective and affordable medicine.”

In  December,  2014, a resolution was put to the Secretary - General  of the UN calling for reform.  “We must continue to remedy the policy incoherence current in modes of international governance in matters of trade, finance and investment on one hand, and our norms and standards for labour, the environment, human rights and sustainability on  the other.”

Great!

For many people, changes to  TRIPS would be welcome and could not come too soon.

Charles Chauvel – thank you for your address and please keep up  your good work.

Darcy Smith

Good evening everyone! Here are some ‘take home’ points from the conference today:

1.     The HPTN052 trial did not stop in 2011 - contrary to popular belief. This landmark study published interim results in 2011 showing a marked (96%) decrease in HIV transmission rates in discordant heterosexual couples when ARV therapy was commenced early versus delayed therapy.The study continued, but in light of the new data all participants were offered ARVs.There have only been 8 HIV transmissions since then on the study. 4 of these were people who acquired HIV at the same time as commencing ARVs. The other 4 cases were in the context of treatment failure with detectable viral load.In other words no transmissions have occurred when HIV replication is suppressed – exciting news!

2.     We now have irrevocable evidence that all people with HIV should be offered antiretroviral therapy regardless of CD4 count. However the WHO have yet to update their guidelines, and the logistics of global access to ARVs are massive.

3.     Doxycycline “syphylaxis” is effective and well tolerated.  In a small study of people taking doxy 100mg daily for 48 weeks, there was a 77% retention rate and a 73% decrease in STI acquisition (gono, chlamydia and syphilis). Worth considering in high risk patients.

4.     For early syphilis only one dose of benzathine is required for HIV pos patients (not 3 as previously recommended).

5.     5-15% of pregnant women worldwide have a curable STI, but only 5-6 countries have a documented policy of screening for STIs during pregnancy. Globally many women attend a health care provider just once during their pregnancy, and symptomatic STIs are treated on the spot. Given that 80% of STIs are asymptomatic many are missed and can cause adverse pregnancy outcomes and MTCT. We need to improve pregnancy outcomes in high burden low income settings, including making point of care testing for STIs readily available and affordable.

Really enjoyed today's informative and cutting edge sessions, ASHM have set the bar high!, looking forward to tomorrow.

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An interesting first day with varied sessions. It was great to hear about a number of very positive treatment approaches using the newer drug options for HCV, the direct acting antivirals. The afternoon session "Ending HCV in Populations" included Professor Greg Dore on HCV treatment as prevention in prisons and Professor Margaret Hellard on treatment and prevention to eliminate HCV in people who inject drugs.

Prof Dore indicated that of the 30,775 Australian prison population there is 30% HCV prevalence but with HCV antibody prevalence in prisoners varying across the states e.g. 52% in QLD, 26% in NSW, 25% in VIC. In prisons there is 60% prevalence of injecting drug use, with 10-15% annual transmission of HCV yet currently no preventative vaccines available, no needle and syringe programs and limited harm reduction methods available. With the new treatment options there is a much greater scope for targeting treatment of larger numbers of prisoners, with the SToP-C study addressing this. 

Margaret Hellard highlighted a shift in focus of who to target in treatment of HCV and expectations re the impact it produces. With 8,000 to 10,000 new HCV infections annually and PWID key drivers of HCV transmission, she stressed that you don't need to treat everybody with HCV to get a reduction in prevalence. If 40 out of 1,000 PWID are treated it can have a significant impact - it would reduce HCV prevalence by 50% over 15 years.  

With the new and future HCV treatment regimes having fewer side effects, high effectiveness, allowing improved dosing schedules and shorter treatment duration it will allow different models of treatment. From work by the Burnet Institute it has been found that social networks of PWID substantially impact transmission rates. A "treat your friends" strategy - treating certain individuals of the network they inject with - could lead to reductions in risk of HCV reinfection post-treatment, and reduce HCV transmission through the network. The TAP study will assess community based treatment of PWID and their injecting networks, looking at rates of HCV primary infection and reinfection.

The take home message from these talks is that with direct acting antivirals for HCV there are now new opportunities to scale up treatments and look at different approaches to treating populations in need. 

STI AND HIV IN PREGNANCY

Yes well done Cuba.

Natholie Broutet from WHO guided us through that country's journey of strategies implemented to achieve this wonderful milestone.We were Iinvited to take away the published booklet from WHO , that sets out the criteria and process for validation.

The session reiterated previous evidence of the global scale of  the prevalence and impact of STI's on people particularly vulnerable populations. Pregnant women are a significant population of vulnerable persons, this was highlighted by the next speaker .Dr John Kinuthia presented on current practices,  limitations of resources for optimal screening tests, diagnostics and time to treat if positive. He discussed the current guidelines of syndromic treatment, whilst is effective in poorly resourced services it misses the asymptomatic clients and sexual partners. One discussion related to the acceptability of partner delivered treatment, which in one study in Kenya appeared to be well accepted by the women and their male partners.

POINT OF CARE testing and treatment has ben widely discussed during the World STI/HIV conference and continued today in relation to STI  testing and treatment for women who are pregnant in rural and remote areas.Dr Andrew Vallely informed us about the research that has yet to commence recruitment in PNG, which they will attempt to provide the evidence that these new technologies will have a positive impact in reducing the burden of disease of STI's in pregnant women.

The afternoon session: O21 - HIV and co-morbidity started with two speakers who complemented each others presentations very well.  

Dr Paddy Mallon provided an excellent overview of the cardiovascular risk factors associated not only with HIV itself, but the ART used in its management - especially abacavir.

Importantly he provided an overview on the potential role of increased platelet activity and their role in increasing the risk of vascular events and thrombosis. He concluded with reference to a current trial of pitavastatin to assess its potential in reducing hyperlypidaemic risk.  

Dr Janine Trevillyan followed on with an excellent overview of why HIV patients are at increased risk of CVD including dyslipidaemias, immune activation, platelet activity and other risk factors such as a higher incidence of smoking and diabetes.  

Janine then provided an overview of her current research activities on platelet derived soluble glycoprotein VI (sGPVI), where she described the observation that sGPVI levels are reduced in the month preceding a cardiac event in HIV positive patients and may have an important role in promoting cardiovascular disease in this population.  It was postulated that this reduction in levels may be linked to a pathological process leading to MI, or sign of an unstable plaque.

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!

There were many highlights today but I will focus on some of the topics that resonated most with me related to technologies or interventions which could benefit marginalised groups in Australia. 

- Shoena Mitchell-Foster spoke on the higher uptake of self collected specimens versus othere traditional methods for cervical screening in a low income country setting in both HIV positive  and negative women. This study identified some of the barriers to traditional testing including the invasive nature of a pelvic examination and cultural considerations. Also to consider is ease of access to a primary health care provider particularly in very remote areas. Self collected specimens could negate the need for nurses or doctors to perform a Pap test. Considering the lower rates of cervical screening in Australian indigenous women, a national screening program using self collected specimens could be of great benefit in both urban and rural settings.

- Gail Matthews spoke about the CEASE study. She showed an excellent slide which illustrated the dense concentration of people co-infected with HIV and HCV in Sydney, NSW.. The slide also supported the idea that this would mean access to most of the clients could occur through only five or so health services where many of these individuals were already linked in. There are also a number of community S100 prescribers in the area. Eradication of HCV in this group seems a realistic prospect as many are well engaged with services however there is possibly a subgroup of very marginalised individuals who may find adherence more challenging and may require additional support to access and complete treatment. Definitely exciting times ahead in relation to HCV treatment!

- Prof Greg Dore spoke about HCV prevention and treatment in the criminal justice setting. Although not without its challenges, prison is quite a good setting to initiate, if not complete HCV treatment. The overall prevalence rate is a staggering 50% including the inmates who do not reporting injecting drug use. The nurse-led model is a fantastic way to increase access for  a population in great need and it's also a wonderful opportunity for nurses to use and develop skills and to work in an autonomous role. 

Looking forward to tomorrow's sessions!

What a start to the conference!

The theme of harnessing HIV and STI prevention opportunities rang throughout the hall during the plenary sessions - and continued to echo throughout the presentations.

Of particular note (for me) was the Causal Interactions Session - specifically the ‘Mega Model’ session presented initially by Marissa Becker and later by James Blanchard. At the base of these talks were the Mega Model diagram and a central concept of fluidity in program design approach. He asks us to specifically consider population transmission dynamics and individual risk, namely looking at biology, behaviour and networks when planning research and developing projects. Blanchard illustrated his ideas through asking the group: why do populations that look similar often have very different HIV epidemics?

The mega model helps address this. In part, this diagram takes a look at how we can modify our approach to problems and adjust our actions along what is occurring in a group or individual’s time line. Without getting too complicated, his argument is that for every phase in a timeline, we should be examining what is actually happening for people during each phase or ‘window’ of the continuum. This is done by considering each phase by analysing 1. Behaviours of groups/individuals 2. Networks that affect group/individual decision making and 3. Biological influences that impact on health changes/disease processes during each window.

An example might be a woman is sexually active at age 14, has casual partners for 2 years, commences sex work in a brothel for 4 years and then ceases sex work. In addition to larger influences, say limited access to education or gender violence, these timeline windows or phases can be examined for influences. Behaviour might include early sexual debut, Networks she interacts within might be intergenerational relationships and Biologically, an immature cervix and high levels of inflammation play significant roles on the trajectory of her timeline.  Different influences at each window will be affecting her individually but they can also change how a program or intervention might be aimed.

By examining the nuances of individual and group timelines, you can negotiate and recognise the smaller differences that can greatly influence group outcomes.

Essentially, we should be approaching problems in a flexible manner that considers all angles of influence for a group or individual PRIOR to instituting a program. This would help stop a ‘one size fits all’ approach while recognizing and accounting for variables that have previously gone unrecognized or acknowledged in program or study development. This will allow us to closely examine the influence of individual or group variables more fully.

It is much simpler than it sounds! Of course, everyone has their favourite method but I saw this as a thoughtful approach to research and project development.

Hi everyone,

Another excellent plenary session presentation with some clinically relevant findings for primary care physicians and health promotion teams.

Associate professor Jo-Ann Passmore, from the University of Cape Town where she also heads the Genital mucosal and STI laboratory gave an insightful presentation on the association between genital tract immunity and susceptibility to HIV and STIs. Her group investigated the markers of inflammation on the vaginal mucosal in South African women prior to acquisition of HIV infection. They measured series of inflammatory cytokines and did screening for the STIs.

Interestingly, they found increased levels of pro inflammatory cytokines MIP-1β, MIP-1α which bind to the HIV CCR5 and facilitate entry of the HIV into the target cells. They also reported increased levels IP-10, and IL-8. The risk of HIV acquisition was significantly higher in women with evidence of genital inflammation, defined by at least 5 of the 9 inflammatory cytokines being raised [OR 3.2; 95% CI 1.3-7.9].

Amongst the STIs, Chlamydia was found to be the most inflammatory STI, while Bacterial Vaginosis was also associated with upregulation of the pro inflammatory cytokines.

Another interesting finding from this study was that there was no correlation between increased genital inflammatory cytokines and the plasma inflammatory cytokines. The clinical and immunological relevance of this finding in the context of long term immune activation for those who eventually got infected and the utility of genital inflammatory markers in clinical practice remains to be seen.

Although this study was done in South Africa, The findings further highlight the importance of screening for STIs particularly for all sexually active adolescents and women even in Australian setting. Also for health care providers and health promotion teams working with CALD communities  and Sex workers, this is work provide another compelling evidence for ramping up STI testing campaigns in order to reduce the new transmission of HIV  and other STIs.

This symposium was a very interesting one presented by Prof. Brian Gazzard. 

Prof. Gazzard discussed different types of HIV client care, of which he advocates Patient Centred Options and discussed barriers to comliance of HIV clients taking and adhering to ART medication regimes.

Following this, Jenny Brockie convened a discussuion between a panel of a HIV doctor, HIV nurse, and the audience. Three Scenarios A or Scenario B of ART choices were presented and the audience had to choose which scenario they think their HIV client would choose. One scenario was having the choice of ART which needs o be taken with food, or ART which does not need to be taken with food. A choice of ART which induces slow CD4 increase and causes no diarrhoea, or ART which induces fast CD4 rises but causes diarrhoea.

Interesting discussions and rationales for different decision making were heard from a variety of doctor, nurse, and patient perspectives.

Some of the key points taken from this symposium in regard to ART perspectives were;

-HIV clients need to be the centre of their own care

-ART and clinical care needs to be cost effective

-Single dose regimes are the way to go if possible

-Interactions and toxicities of ART are important factors

-Patient advocacy needs to include understanding how ART impacts a PLWH day to day life

Last but not least be honest with your patients, and know more about ART than your patients so they can make informed decisions.

Congratulations to Cuba! 

Certified as having eliminated HIV & Syphilis transmission from mother to child.

In 2007 the WHO developed the elimination of MTCT policy - all regions have been working towards elimination. There is a structured validation process to approve and celebrate successful countries/regions. Cuba is the first country to reach this target!

Worldwide there's much work to be done - almost 1,000,000 pregnant women have HIV. Assuming  a rate of 2% MTCT, there are a still a number of children diagnosed and a significant number more at risk. 

There seems to be a high risk of Cardiovascular Disease in HIV positive clients,even without cardiovascular risk factors.

Abacavir causes a platelet reactivity in HIV infected clients,this increases risk of thrombus,thus increasing risk of Myocardial Infarction.

Dyslipidaemia is now actually lower now than previously.Cholesterol levels now in clients with HIV now lower and better monitored than HIV negative clients.

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. 

I have always had doubts about PrEP and social responsibility, but after listening to some of these very informative talks,it has occurred to me that people have the right to access this treatment.I listened with interest that it has yet to be approved by the PBAC for this reason but it raises the question that if it was a socially acceptable disease would PrEP be approved by the PBAC straight away.

It seems the eligibility to qualify for PrEP is high risk behaviours, but if I am HIV positive should my negative partner not be able to qualify for PrEP? Could not making PrEP widely available be a means to ending the stigma associated with HIV.

These talks have raised many issues with me:

1) Do people now stop using condoms (I know some people who have utilised PrEP for this !!!)

2) If a high risk client is not adhering to safe sex, then will their adherence to PrEP be any better?

These talks has left me in two minds: that we seem to be encouraging a society of little or no responsibility.

But on the other hand people have the right to have sex without a condom.

Great double session by John De Wit who discussed the current state of play with the VICPrEP study.

In summary - PrEP works! There have been a number of RCTs showing decreased HIV acquisition with PrEP. Of course, adherence is paramount to success.

One of the concerns put forward is that PrEP use may decrease condom use; risk compensation. 

VIC PrEP, thus far, has been a demonstration project. They have undertaken a multI-site , open label study. Participants have taken Truvada daily for 12 months.The 92 participants with follow up data took regular surveys to examine attitudes and behaviours regarding PrEP. 

They looked at the amount of regular & casual partners, frequency of sex as well as risk reduction methods - Serosorting, VL sorting, positioning, withdrawal and condom use. Interestingly , there was no change in sexual behaviour with regular partners while the main  significant change in behaviour with casual partners was some decrease in condom use. What does this mean? well, Yet to be determined as adherence to PrEP was generally very good.

However, it's  most important that PrEP is part of comprehensive package - with STI screening, condom use promotion. 

Look forward to further data from this study!

Iryna Zablotska gave a conservative estimate of the number of people in Australia who will be likely to start PrEP if it is approved by the TGA. She also highlighted some of the difficulties in making such estimates.

John de Witt gave two interesting presentations on data from the VicPrEP trial. His first presentation outlined their findings on "risk compensation" in those on PrEP. They found a modest decrease in condom use with casual sexual partners amongst VicPrEP participants. Reassuringly, they also found good self-reported PrEP adherence, so the reduction in condom use will hopefully not translate into an increase in HIV risk.

John's second presentation provided a summary of the experiences reported by people taking PrEP. Participants reported increased enjoyment of sex, but also reported some reluctance to inform sex partners that they were taking PrEP. The latter suggests the emergence of stigma, or perceived stigma, associated with PrEP use.

HIV and Women's Health was the topic of Wednesday morning's stream. Much interesting and varied work was presented. I will attempt to summarise below.

Damian Jeremia presented his work entitled Prevalence and Factors Associated with Modern Contraceptive use among HIV-positive women aged 15-49 years in Kilimanjaro region, Northern Tanzania.

Women's responses to a questionnaire and interview in Swahili language were aggregated. Results showed that only 54% of these women were using a form of modern contraception. Male condoms were the most common contraceptive method (25.4%). He cited lack of contraception information and lack of combined reproductive health and HIV services being the main barriers in contraception use. 

Dr Lisa Noguchi presented on some complex findings from women participating in the S African-based VOICE trial. The VOICE trial is a Phase 2B trial of women using tenofavir as HIV prevention, and one of the eligibilty criteria required having effective contraception.  Lisa's secondary analysis of the data looked at injectable Progestin contraception and acquisition of HSV2 Infection. Injectable progestins are the most common contraceptives used in S Africa. Whilst some data suggests hormonal contraception may increase HIV-1 risk for women, recent studies have suggested there are differences in this risk between the 2 commonly available progestin injectables - DMPA and NET-EN. Retrospective analysis of the VOICE data showed HIV-1 was higher for users of DMPA vs. NET-EN (aHR 1.41, 95% CI 1.06-1.89) p=0.02.   However, the risk of HSV-2 acquisition  between the 2 types of injectables turned out to be not significantly different.     She noted that the data was extracted from the VOICE study retrospectively, which was originally designed to demonstrate different data and results could therefore be prone to bias.

Shaun Barnabas presented longditudinal cohort data on genital symptoms and STIs in just under 300 women aged 16-22 years in different cities of S Africa. The Cape Town cohort was more risky in behaviour with a high prevalence in STIs vs. Johannesburg, specifically a higher prevalence of chlamdyia, gonorrhoea and HSV-2. There were low rates of symptoms reported across the board,with "normal vaginal discharge" being the most common symptom (58%) and "abnormal discharge" 8% at baseline.There was little correlation between symptoms and STIs. This is an issue as S African guidelines are based on syndromic management, thus potential for under treatment is significant. 

His final question was "Is it time for the SA government to move away from syndromic management?"  The resounding answer from the audience response was "Yes!".

Alison Norris educated us about the gender differences in HIV testing and knowledge in Rural Malawi, one of the poorest per capita countries in the world. There were encouragingly very high rates of HIV testing in both sexes. Most powerful predictor in whether someone of either sex had ever had an HIV test was knowing the partner had received a test. Ultimately their prediction that there would be significant differences between testing and knowledge between men and women was unfounded.

A/Prof Sheona Mitchell talked on uptake of cervical cancer screening among HIV positive women participating in a pilot RCT in Uganda: the ASPIRE project (a collaborative study between Canada and Uganda).  The aim of the ASPIRE project is to inform policy makers about cervical screening programs in resource poor areas.

They studied 500 women in an urban community in Kampala. Usual cervical screening involves visual pelvic speculum exam with acetic acid application.ie invasive. The potential for a less invasive test such as a self-collected swab detecting high-risk HPV strains is a novel, attractive approach for low-resource settings. HIV positive and negative women were randomised to speculum visual exam or self-collected swab. 

Self collection of swabs had a high uptake in both HIV pos and neg women. It was found to highly acceptable, improved access and had high rates of retention going forward to further exam and treatment (compared to visual exam alone).  She was hopeful of future POCT for the HPV swab to further reduce barriers to cervical screening uptake. 

Elizabeth Fearon then finished up the session by presenting interesting data on a method to estimate the national prevalence of HIV among female sex workers in Zimbabwe by pooling data from Multiple Sampling Surveys and Programme Consultations.

My take home message from all of the above presentations is that there is much great innovative research going on in some of the most resource-stretched places on Earth.   Many small steps are being made towards improving access to screening, testing, support and treatment for women (both HIV positive and negative) from these difficult to reach populations and places.  But there is still a long way to go.

In this plenary session, Professor Myron S Cohen presented summary of the HPTN 052 study. This study assesses the risk of HIV transmission in couples where the HIV positive partner is either treated early, compared to couples where the treatment of the positive partner is delayed. Contrary to some medical media reports, the HPTN 052 study is ongoing, in 2015 some 1535 participants remain enrolled, and over 9000 years of follow-up have been completed. Participants are allowed to bring new partners into the study.

Prof Cohen reported an overall 93% reduction in the risk of transmission in those couples where the positive partner was started on ART early versus the risk in those couples where ART treatment was delayed. However, Prof Cohen stated that the actual risk reduction is probably closer to 100%, based on the following analysis of linked transmissions:

- In total 8 linked infections occurred after the index started ART

- 4 were diagnosed soon after the index started ART, raising the possibility that these transmission occurred before the index attained virologic suppression.

- 4 occurred after the index failed ART

- No infections were observed when HIV replication was suppressed.

Prof Cohen also shared his thoughts on starting ART during primary HIV infection (PHI), at the time of diagnosis. He argued that people should start ART immediately, whenever this is possible, citing the following reasons:

- If ART is commenced before people have a drop in CD4 number, then they are likely to have a healthy CD4 count in the long term.

- Starting ART immediately possibly reduces the latent reservoir, which could provide patients a better chance of cure if and when this becomes available.

- During PHI patients have extremely high serum viral loads, which possibly increases the risk of onward transmission.

Prof Cohen acknowledged that these points have been disputed by other HIV researchers, and the question of immediate treatment at the time of diagnosis has not yet been settled. Several studies are hoping to address this question over the next few years.

Prof Myron Cohen, the lead investigator of the multinational HPTN052 trial kicked off today's Plenary clinical presentations with Treatment to Prevent HIV: Does timing matter?

Great overview mentioning that risk of transmission is explicitly related to viral load. 

His breaking news: HPTN052 trial has found an overall 93% risk reduction of contracting HIV in ITT analysis of sero-discordant couples. And even better news was that the 8 linked partner infections that occurred whilst their partner was on ARTs occurred either before ART was commenced or when the partner was actually failing ART therapy (i.e. had a detectable viral load).

This means NO infections were observed when the partners' HIV replication was suppressed. 

He then highlighted that a significant proportion (19-52%) of HIV transmissions occur during early/ acute infections, adding much weight to the argument for very early ART treatment.  

His message was applauded and was loud and clear to "Start ART Now!" 

a good start to the day with  great welcome by Aunty Carol Currie, there was an interesting talk by the QLD minister for health on future directions  for health care in the sexual health sector.

Robert Mitchell  provided an excellent insight into future directions for HIV care and the big need for people with HIV to be included on any decision making authorities

Bridget Haire highlighted the poor uptake of the use of PreP by government Authorities

Professor Cohen provided a talk on the prevention of utilising antiretrovirals to prevent HIV,his trials have shown that with antiretrovirals and counselling ,96% of trial couples did not become HIV positive.

Transmissions have plummeted with the use of antiretrovirals as a preventative measure

Hurrah finally some form of preventative measure,but you do have to think about the side effects of the antiretrovirals and the accessibility  of these melds to the people that most need them.