prevention of harm - including early ART initiation

Next up for me today was the Epidemiological challenges of HIV surveillance presented by Anastasia Pharris.European Centre for Disease Prevention and Control (ECDC) in Stockholm, Sweden  Anastasia showed data highlighting the contrast in reported routes of HIV transmission by European sub-regions in 2015 across the West, Centre and East.  Heterosexual transmission accounting for a significant portion across all areas, injecting drug use significantly more in the East and MSM transmission more in the west and centre.  She demonstrated that sex between men is significantly underreported and stigma and discrimination is still a huge barrier. Anastasia commented that Europe is lagging behind in its response to the HIV epidemic and it is not on track to reach the 2020 targets.  She highlighted there are some issues urgently still needing to be tackled, one in particular is the development of policy to include undocumented migrants which account for a proportion of the late presentations and also community viral load which has public health implication.  Finally she talked about more wide scale role out of some successful models such as community based testing, home sampling, PrEP scale up, harm reduction efforts such as needle syringe programmes and opiate substitution programmes and reduction of stigma.

Following on from the breakfast buffet of the bright future for ART and European epidemiology I moved on to the Industry sponsored degustation menu of case studies entitled “Seeing the whole picture” presented by Giovanni Di Perri, Professor of Infectious Diseases at the University of Turin, Italy  & Jürgen Rockstroh, Professor of Medicine and Head of the HIV Outpatient Clinic at the University of Bonn in Germany and a panel of experts. 

Giovanni Di Perri opened the session discussing the prevention of harm in patients with HIV and detailed the common comorbidities associated with HIV and the impact of long term ART such as neurological impairments, cancer, CVD, Bone disease, liver and kidney disease. He highlights the need to carefully manage our patients as a whole, going beyond undetectable, to improve their overall health by considering comorbidities (prevent and treat), counselling our patients on lifestyle risk factors and careful selection of ARTs that balance HIV efficacy, durability and toxicity.  3 case studies were then presented by panel members focusing on differing disease burdens such as bone density, renal function, and prevention in the healthy client with lifestyle factors such as smoking.  Audience participation was required for responses on care priorities, comorbidity treatment options, ART switches and perhaps the one with the most diverse spread of results was in answer to the question when to start ART treatment in the case of a 23yr old MSM diagnosed with HIV that day.  40.4% of the audience said ‘immediately (today)’, 43.8% said ‘once all baseline data were available’, 1.1% answered ‘CD4<500’, 1.7% said ‘Wait, this patient is too young to start lifelong therapy’, and 12.9% said ‘Wait – I need to assess whether this patient will be adherent’.  In this panel discussion reference was made to the San Francisco experience of same-day observed ART initiation versus standard of care and its benefits to viral suppression.  Overall feeling from the panel was a slightly more cautious approach to treatment initiation where one awaits resistance profiling and other baseline assessments before commencing ART to allow for adequate characterisation of any co-morbidities and also time to spend with the client getting to understand their wishes, likely adherence and willingness to start therapy.

And so concludes the second day of yet more mouthwatering (or rather thought provoking) messages and i look forward once again to more palate pleasers tomorrow!