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.

So far there have been two well documented cases of individuals on PrEP contracting HIV despite good adherence and high TDF levels. This poster presents a case where a 50 year old gentleman, who had optimal TDF levels (on 2 dried blood spot examinations) - 8 months in to the AMPrEP study he tested antibody reactive, antigen negative on a 4th generation Ab/Ag HIV test. During this visit he described symptoms of fever and dysuria. Western blot reveleaved a single band at gp160. At the time the patient had tested negative on pol PCR (DNA and RNA) of bulk PBMCs and sigmoid colon biopsy, and had no detectable HIV viral load. PrEP was subsequently stopped due to concerns around inducing resistance (looks like this was done within a few days of the results - see attached poster). 3 weeks later, HIV RNA was detected in plasma (40,000 copies/ml). No resistance mutations were identified. The patient was commenced on treatment and 1 month later had an undetectable viral load.

 

The presenter highlights this as being a probable third case of HIV seroconversion in a PrEP-adherent individual. This would be a first case of wild-type virus being transmitted under these conditions. They postulate possible reasons for PrEP failure such as very high exposures, and repeated trauma.

 

What’s not clear to me is whether the possibility of a false reactive HIV Ab/Ag was considered. The poster does not detail the reactivity score (i.e. was this a borderline result) on the LIAISON XL platform. If this result was a borderline reactive, was this more of a PEP failure, i.e. the patient did not have a long enough PrEP-tail following last UPAI, or was this indeed a PrEP failure? Did they stop the PrEP too soon? This brings us to question how we go about managing indeterminate HIV results in the the context of PrEP.

 

What do you think?

Tagged in: CROI 2017

Wednesday morning featured a series of oral presentations exploring the interplay of STIs and altered microbiomes might affect PrEP.

Renee Heffron presented research that explored whether bacterial vaginitis decreased the effectiveness of oral PrEP.

In the CAPRISA 004 study which demonstrated the effectiveness of intravaginal tenofovir it was observed that in women that had a vaginal biome consistent with BV there was a significantly decreased effectiveness of vaginal tenofovir gel. It is postulated that anaeobic bacteria may hasten the breakdown of tenofovir. This study explored data from the PARTNERS PrEP study .  It compared baseline vaginal swabs , graded using the nugent scale as to the number of BV related bacteria, with serum tenofovir levels and HIV seroconversion. Reassuringly BV did not seem to affect either Serum levels or PrEP effectInness.

 

John-Michel Molina presented an interesting IPERGAY sub study. This looked at the controversial area of STI prevention using Doxycycline PEP. Men enrolled in IPERGAY were randomised to be provided with doxycycline PEP or not provided with PEP. Those asked to take the doxycycline PEP were asked to take a stat dose of 200mg between 1 and 3 days after sex. The time to acquisition of an STI (gonorrhoea , chlamydia or syphilis) was compared. In brief , no effect on gono but significantly reduced rates of syphilis and chlamydia. The data presented didn't address the thorny issue of antibiotic resistance. They are still looking at that.

 

Tagged in: CROI 2017

Day One  Monday  13/2/2017   program : 

1 Molecular virology: advances in  understanding of HIV-1

2 HIV  reservoirs: obstacles to an HIV cure

3 Prevention trial design in the era of PREP

4 Approaches to staging and treatment of  early stage HCV

5 Cirrhosis issues

6 Common drug  interactions with HIV/HCV coinfection

 

 

Tagged in: CROI 2017

Presentation by Andrew Carr.

Bone loss in 1st year of ART is a well established fact.

Loss is more on tenofovir containing regimes 2.4-3.8%  non tenofovir 0.7-2.5%.

Compare to 1 year 10mg prednisolone 0.8 -3% loss

PREP tdf-ftc

4RTC's show 0.5-1.5% loss BMD over 12-30 months!

          Reversible  if stopped  after 1 year

             Reversibility not established for longer periods, prep may be long term

Proportion of those with greater bone is uncertain

            >3% loss at hip and LSS in 25-50%

Non adherence issues in early RCTs , so bone loss may be underestimated.

Study 36 men taking TDF-FTC PrEP on prelude trialNSW,av age 38, av weight 79.9,TDF exposure pretrial 6months.

Average BMD loss - 2.2 spine,-2.5 fem neck,but,approx 45% lost>3%, 25% lost>5% BMD

Study limitations :no control,no women,some loss attribuible to age, 1 year data only,no PK data

Needs:

Longer f/up, data on secondary causes of BMD loss,more patients to identify risks for the greater loss group

 

 

 

 

Quick update on a presentation by John McAllister

 

  • if source VL is undetectable, then PEP is no longer recommended
    • however, do need to discuss the reliability of the history of undetectable VL
  • Truvada should be used for PEP
    • avoid tenofovir and lamivudine (although cheaper)
  • 3-drug PEP
    • if 3 drugs are needed, then stick with dolutegravir (ALT increases by 22%), raltegravir or rilpiravine

 

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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