At the close of the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) that took place from 1 to 3 June 2017 in Hong Kong, faculty members Dr. Charles Boucher and Dr. Patrick Chung-Ki Li quickly presented a few slides showing the breakdown of who attended the conference.

An interesting point (I think) is that as a nurse, many presenters stated that to instigate new ways of working, reaching vulnerable populations and rolling out PrEP, nurses would be the backbone of the work force. Yet, only 5% of the attendees were nurses. To get nurses onboard and understand why they are expected to step up and lead these innovations, more need to attend conferences like #APACC2017.

At one particular session of the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) that took place from 1 to 3 June 2017 in Hong Kong, Dr. Dan Kuritzkes (Harvard Medical School, USA) started his presentation by asking the question, 'Why do we need new drugs?'

The answers being:

• Side effects of current therapies.
• Long term toxicities of current ART.
• Resistance issues.
• Need for less frequent dosing.

He then went on to discuss new medications in development/trials.

DORAVIRINE (NNRTI) — This drug is active against HIV carrying the common NNRTI resistance mutations, it has low potential for drug-drug interactions and has the same efficacy as Effavirenz.

BICTEGRAVIR (INSTI) — Active against wild-type and strains carrying the common INSTI resistance mutations.

Dan went on to discuss the pros and cons of different types of treatment delivery such as injectables.

Pros                                               Cons

Monthly dosing                                 The injection itself may put clients off

More convenient                               Long term tolerability

Less internal stigma                          Long half life

Better adherance                              Cannot be self-administered

An interesting snippet was that TRUVADA is being researched as an injectable. This ties in with Dr. Zhang's presentation who stated that TRUVADA as a single tablet wasnt available in China and called for a new way to deliver this medication especially in the setting of PrEP. Dan mentioned a few other drugs in development but didnt elaborate much on them. These being:

IBALIZUMAB, FOSTEMSAVIR and PRO140.

The summary of Dr. Kuritzkes' session is:

• There are new drugs in several classes undergoing clinical trials.
• Different delivery systems are being researched.
• Novel viral and cellular targets are being explored rather than the traditional classes.
• 2 Drug ART regimens could became the norm rather than 3 drug ART.

This session was delivered by Dr. Andrew Grulich (Kirby Institute, Australia).

Dr. Grulich began by stating that, 'We know PrEP works'. He presented some short soundbytes about lessons learned from PrEP trials in Australia.

-PrEP quickly attracts very high-risk gay men.

-There was high levels of adherance (proven by drug monitoring testing).

-This cohort has high levels of STI's (showing their relative HIV risk).

-No HIV seroconversions seen in about 500 person-years.

As Australia has a concentreated epidemic (~0.1% prevalence in general population v ≤15% in MSM in urban centres), the most impact that PrEP will make is to target high risk MSM. Andrew presented a model that showed that if the high risk MSM group were saturated with PrEP users, it would result in much lower incidences of HIV plus it would have a herd immmunity effect on those in the same sexual networks but not exhibiting as high risk taking behaviour.

Andrew discussed the EPIC study. He discussed how some clinics workloads were much increased due to the amount of MSM on PrEP attending their clinics. This showed that innovation was required to ensure the services continued whilst under great pressure.Thes innovations included:

-Peer led education pre-consent sessions.

-Same day PrEP precriptions.

-Nurse led dispensing/care requiriung only once or twice yearly medical review.

Dr. Grulich asked the question, 'Will PrEP end HIV?' His answer was that whilst safer sex practices and TasP has resulted in stable HIV prevalnce in NSW, it hasnt showed a reduction. He displayed a slide that showed that since the PrEP study was rolled out, HIV prevalnce has REDUCED by 23% in the second half of 2016 in NSW. He did warn that it is too early yet to say PrEP is the reason. More data and time past is required.

He concluded by saying that should PrEP be rolled out as a national startegy, federal government subsidy would be required. The cost may not be as high as first thought as the PBS is considering an application for generic Truvada to be added as a PrEP treatment.

A very brief blog on Hep B treatment and new agents presented by Jürgen Rockstroh

TAF works for Hep B

Here's the data

Can we cure Hep B like Hep C?

Names in black are in the pipeline

These are some stand out points from the  presentations at APACC covering issues related to HIV +ve youth.

#1 cause of death in 18-25 age group in Sub Saharan Africa is HIV/AIDS

#2 cause of death in 18-25 age group globally is HIV/AIDS.

In Asia, 37% of new infections are in adolescents.  HIV +ve adolescents include those infected by MTCT and those infected through sex and IDU. 

Rates of mental health diagnoses and neurocognitive issues are high in HIV +ve adolescents.  Dr Warren Ng, a psychiatrist from Columbia University, USA has worked with HIV +ve young people for many years.  He explained that the grey matter in the brain peaks during early adolescence.  This is also a time of increases in gonodal and stress hormones. Mental capacity continues to develop during the 20s.  Those most at risk of psychological morbidity include ethnic minorities, those living in poverty, or experiencing psycho-social trauma, substance abuse and inter-generational trauma. 

Age appropriate disclosure of HIV status requires teamwork and planning.  Transition to adult services needs to be staged and should only be commenced after the young person knows their status.  Dr Rangsima Lolekha, shared the data on a cohort of MTCT HIV +ve youth in Thailand. Transition to adult care usually occurs around age 21.  The risk of death at this time for these young HIV +ve people is five times that of age matched HIV -ve young people.  This vulnerable time is characterised by issues relating to transport, economics, health insurance and less rigorous systems to track continuing care.

It is Saturday evening and the conference is over.  I have been sitting and reflecting on the experience of the last few days.  Our global political climate is becoming more conservative and less inclusive.  With summary executions of people who inject drugs in the Philippines, the leader of the opposition in Malaysia still in jail on "sodomy charges" and public whippings of male homosexuals in Banda Aceh, this shift is clearly gathering momentum in South East Asia.  

There is so much at stake.  The HIV and BBV sector in Health has spent decades studying and sharing the science around harm minimisation and access to healthcare for all.  We continue to champion the removal of stigma associated with HIV, sex work, same sex attraction, injecting drug use and transgender health. There are countless studies that show this approach is cost effective. Prohibition and punishment drive these behaviours underground, as people become too fearful of their safety, to access services.

Dr Adeeba Kamarulzaman, Dean of the Faculty of Medicine at University Malaya Medical Centre, was heading home after the APACC conference, to discuss these issues with a peak group of muftis in Malaysia.  She has been examining the Quran and has found many passages of the text that support the compassionate treatment of all people and the use of harm minimisation principles.  The tension between religion, health and politics has the potential to derail many of the public health gains we have made to date. 

We need to keep reminding our politicians and administrators of the Public Health principles that we know work. It is vital that we use our collective voice to call out stigma and discrimination when we witness it in our workplaces, communities and in the attitudes of our colleagues.  

A picture paints a thousand words - Dual Drug Therapy.. a blog in pictures (a Plog?)

This is the history of therapies in HIV

3 drugs work, why are we going back to 2? It's not like we haven't done it before with poor results

Why do we even need a 2 drug regimen

Some definitely don't work - don't try these at home, but some bear looking at again

Eg.

and

Hmmm

Think about this

Is DTG the deal breaker?

PADDLE - the proof of concept

The follow on is GEMINI 1 and 2, current Phase 3 trials - data to follow........

Watch this space?

Day 1 of APACC 2017

Other bloggers have written eloquently on sessions on day 1 at this meeting so I thought I might report on my impressions on the 'first 24 hours' of APACC 2017.

At conferences such as these, i am constantly reminded how lucky I am to be practising HIV Medicine in Australia, with universal healthcare and the PBS system for access to medications.

Australian clinicians and leaders in HIV Medicine (both in policy, research and mentoring) have been providing significant, and exemplary, leadership in the Asia Pacific region. This is certainly seen in the high regard and respect that is extended to Australian clinicians present at APACC. I had not realised this, but now wonder if there has been any interchange of knowledge at the 'grassroots' level of HIV care. I believe that we have a fantastic model of primary care management of HIV in Australia, and wonder if that is translatable to our regional neighbours. This may be an area for further exploration in the future, esp. as the RACGP already has associations with primary care groups in Malaysia and Hong Kong 

Many Asia Pacific countries can be considered 'resource limited' in terms of support from their government/health agencies and limited access to medications eg. China's public health clinicians do not have access to INSTI's or ANY STR's. The Chinese National Free Antiretroviral Treatment Program only has access to 3TC, AZT, d4T, ddI, NVP, TDF and EFV. Most recently LPV/r was added as the 2nd line option. Contrast this to Australian clinicians who are mostly proactively getting rid of Atripla from our medical armamentarium, switching to TAF containing STRs and have access to INSTI's.

Chemsex is also an issue in Hong Kong, as it is in Australia. A poster presentation which surveyed 30 HIV positive men diagnosed recently, revealed that all had used methamphetamine in the context of sex, and 73% of participants fulfilled DSM-IV criteria for stimulant dependence syndrome.

There is a ART backbone 'turf war' going on in the region due to the rise of the concept of dual drug therapy in HIV. In their industry-sponsored symposia, arguments were put forth for maintaining a 3-drug backbone esp with TAF which is not currently in widespread use in the region vs. moving to a 2-drug regimen for naive or switch therapies which has appeal to the region ie less cost. 

As the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) draws to a close I am reinvigorated and ready to implement changes in my own practice.

I was privileged to visit a local health facility and impressed by their ability to treat so many with limited resources. 

Despite the differences, there are many similarities in the emerging health needs of PLHIV and hepatitis C.

• Ageing populations calls for teams of primary healthcare workers.
• Hep C treatments are rapidly expanding across the Asia Pacific but barriers remain. Primary care seen as important in delivery of treatment in Australia.
• Hep C testing and treatment needed in communities with access to at risk populations.
• PrEP is emerging as the preventative health priority. Innovative approaches being used.
• Stigma and discrimination remains a barrier to access to care.
• Dual therapy ART looking more likely to be effective than not.
• Long acting ART development continues.
• Multiple new DAAs for hepatitis C on the horizon.

I have just finished an APACC promotional video and can recommend this conference to my Australian colleagues for next year.

The efficacy of the HIV medication Truvada as an HIV prophylaxis is very well established in the sexual health and HIV treatment/prevention world. Truvada, better known as PrEP in the HIV prevention context, is made up of the two antiviral medications emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg.

The implementation of PrEP in Asian countries is struggling to get underway in sufficient numbers and the primary reason for this is mostly due to cost. Although, there are other very significant barriers to getting at risk populations on the medication, as a way to reducing the transmission of HIV. Another barrier is that clients do not want to be seen attend clinics for fear of being ‘outed’ as either belonging to the men who have sex with men group (MSM), being transgender (TG) or being recognized as a person who injects drugs, all of which carry extreme risk in certain areas of Asia. The most clearly at risk MSM age group is those 20-24, where the greatest number of new infections are found in Asia.

There are some extremely concerning issues surrounding all of the above at risk groups. Firstly, the MSM group. Currently in Indonesia there are serious concerns arising over some parts of Indonesia whereby gay and bisexual men are being punished and prosecuted for having sex with men or engaging in group sex. Another group suffering stigma and discrimination (and are therefore having problems accessing services) are transgender individuals. The social scientist Martin Choo explained that there have been cases of clinics proving care to transgender clients (an understandably highly disadvantaged group disproportionately affected by serious health concerns) and due to either conflict and or discrimination within the clinic, information was released to the public about the identities of the transgender clients receiving care. This has obviously resulted in a serious breach to personal safety and the ability of those individuals to return to services and receive the care they need. Another example of a serious barrier to accessing PrEP in the Asian region is in the Philippines, where their current stance on drug laws is so severe that services providing NSP paraphernalia can be used against workers, resulting in incarceration. These, and other serious problems in the region are commonplace and illustrate how much work needs to be done to change attitudes and get governments and communities to see the benefits of PrEP (not to mention NSP programs, transgender health and the sex worker communities). Other barriers include a very recent redaction of funds to Vietnam by the USA and accepted public violence towards MSM/TG and other minority groups.

At this stage and from the talks at the APACC, it appears that Thailand, Taiwan and Vietnam are the countries that have so far managed trials or programs whereby these at risk populations can access PrEP and therefore work towards preventing the spread of HIV. I do not believe that any of these countries have any more than a few hundred clients accessing this prophylactic medication. It makes the situation in Australia seem like a paradise for health professionals, clients and governments, whereby there are somewhere in the vicinity of 8000 people accessing this medication. This amazingly positive number of people and positive situation overall (where attitudes allow for this to happen on an individual level and at a state government level) is believed so far to have resulted in a reduction of HIV infections by about 25%, which is a conservative number. One speaker mentioned that the gay dating app Blued has somewhere in the vicinity of 27 million users in China. This is an enormous number of at risk clients and a group that would very greatly benefit from the medication and make a huge difference in the global fight against HIV.

There is currently a global target in place (apologies I am not aware of the origin of this statistic) to get 3 million people at substantial risk on PrEP. As of October 2016, only around 100,000 people were able to access the medication. It is very clear that a lot of work needs to be done to change attitudes to PrEP, develop protocols, convince governments to assist in funding such programs and using this very effective medication to reduce the global burden of HIV.

Recruiting people into HIV services
Panus Na Nakorn

The breakout session PA_9 was entitled, 'Innovative HIV testing, prevention and care service delivery models' with the first speaker Dr. Panus Na Nakorn presenting a session entitled, 'Recruiting people into HIV services: ebooking'. He told us that this model of care was Thailand-based where their 90-90-90 figures were 82-72-79 in 2014. The 90-90-90 is an indicator of how well countries are providing HIV treatment. It represents the percentage of people diagnosed-the percentage of those people on treatment-the percentage of those who are virally suppressed. He broke those figures down for MSM and they were poor reading as 19-37-65.

The speaker then discussed the Thai national strategic framework to end AIDS. He discussed current (offline) interventions where peer to peer and social networks are the most common way of trying to get get people to attend for testing. The speaker highlighted an interesting fact about internet use in Thailand - MSM and TransFemales spent more time on the Internet than other groups. To capitalise on this, a MSM specific site was created called 'Adam's Love Site'. This site was very well accessed and resulted in 20000 visitors to clinics for HIV and STI testing. This result showed that the internet could be a way of reaching MSM and getting them tested and into treatment. Dr. Nakorn explained how the ebooking system worked. After logging into the website, the client took a quick survey about any risk taking behaviours. If any were highlighted, they would be offered a test at a centre of their choosing and at a time/date convenient to them. The client filled out a form online and this gave the client a unique code. This code was sent to the centre they had chosen so when the client attended the centre already knew why they were there. Confidentiality was therefore maintained throughout. 
Dr. Nakorn completed his session by saying that ICT and social media needs to be embraced as way to reach key populations in this age of technology.

This sentiment has also been echoed by DR. Chris Beyrer who in a discussion session yesterday said (not verbatim) '...services need to go where the people are. Thats where the outreach principle came from. People now live in a virtual world. That's where the services need to go.'

Wise words.

Rajasthan, R, Malaysia ; HIV and ageing Study.

One of the emerging challenges is the ageing cohort of PLWHIV within Australia. Many of these individuals have complex co-morbidities requiring experienced clinicians and team based models of care.

Dutch data indicates that 2 of 3 HIV positive individuals within Holland will be aged >50 by 2025. Similar trends are expected in Australia.

There were many sessions and posters looking at co-morbidities and ageing.

Many abstracts highlighted the increased prevalence of CKD, atherosclerosis, peripheral neuropathy, neurocognitive decline, diabetes and osteoporosis in PLWHIV. Ruzicka D Japan, Rajasuriar R Malaysia, to name a few of the many presenters.

Reena Rajasuriar presented findings from the Malaysian HIV and ageing Study.

Attempts were made to adequately match study participants. The concept of functional age was a central tenant of the design. Prior studies were highlighted for lack of adequate controls and use of subjective, poorly validated measuring tools. Dr Rajasuriar commented that single entities are often used to measure the ageing syndrome.

The Malaysian study focused on the multi factorial nature of ageing. The use of comprehensive geriatric assessments were utilised to reduce subjectivity bias.

All 10 markers of ageing were increased in the HIV positive arm compared to matched HIV negative participants.

• 2.5 times reduction in QOL indicators.
• 4 fold increase in mortality
• 5 fold greater utilisation of health services.
• Significantly more sarcopenia and functional disability.

New models of care were called for throughout the Asia Pacific region. In particular multidisciplinary teams, including but not limited to, social workers, dietitians, psychologists, nurses, GPs, physiotherapists, podiatrist and exercise physiologists.

Comprehensive geriatric assessments were heralded as ideal.

Much panel discussion was generated through audience participation

• Is this a realistic concept?
• Is the process clinician driven or patient driven?
• What management strategies are cost effective?
• How do we manage the increasing burden of subcortical neurodegeneration?

This session was very informative generating much discussion amongst my Australian colleagues.

As demand for complex services increase service innovation will be required.

Australia is proposing a new patient centric and patient driven model of care. Health care homes as primary care coordinators are also a central  theme. This model is well suited to providing innovative care to the ageing population of PLWHIV.

Management of traditional lifestyle risk factors remains central to managing cognitive decline.

Focusing on functional age is increasingly seen as a more useful measure of healthcare needs rather than numbers of co-morbid conditions. 

Doyle,J (session presentation) ; coEC Study

Lu,Y (2 poster presentations) ; ASTRAL-5 Study

This presentation by J Doyle from the Burnet Institute highlighted the findings from the first year of the co-EC study in Melbourne. Modelling presented by Scott, et al at EASL 2017, proposes that treatment of 515 co-infected individuals in Victoria will reduce the prevalence of hepatitis C within the GBM community by 80%.

In the first year clinical data was collected on 160 chronic HIV/HepC co-infected individuals on ART. This included biochemical, haematological and fibrosis data. Primary care clinicians assessed this data and individuals either:

• received immediate DAA therapy (40%)
• received DAA therapy after specialist advice (31%)
• were referred for specialist care (19%)

Referrals were predominantly required for known cirrhosis, APRI score >1, malignancy, renal/cardiac disease or fibroscan >12.5Kp.

This study highlighted the capacity for the majority of non-cirrhotic HIV/Hepatitis C individuals to be effectively managed by a primary care clinical team. This model of care fits comfortably with Australia's move toward patient centred, community based care within health care homes. 

ASTRAL-5 (2 poster presentations)

The efficacy, tolerability and safety of Sofosbuvir / Velpatasavir in HIV / Hep C co-infection was presented. 106 patients were enrolled for 12 weeks of SOF/VEL therapy. SVR at 12 weeks was demonstrated in the majority of patients across the 5 genotypical variants assessed. 

ASTRAL-5: SVR12 rates by genotype.

•        Genotype                             SVR12%   (n/N)
•        Total                                    95%
•        GT1a                                    95%
•        GT1b                                    92%
•        GT2                                     100%
•        GT3                                      92%
•        GT4                                     100%

No patient experienced HIV virological rebound.

Side effects were similar to other available DAAs with fatigue (25%), headache (13%) and nausea (7%) reported. 

• Drug-Drug interaction studies demonstrated no clinically significant interaction with a wide range of commonly used ART regimes. The only exception is that of EFV. There was a 53% reduction in VEL levels and thus EFV is currently not recommended for use with Velpatasvir. 

These presentations highlighted the suitability of primary care teams to effectively manage HIV/Hep C co-infection. This community based, patient centric model of care will enhance our capacity to eliminate Hepatitis C among the HIV cohort within Australia. The combination of Sofosbuvir with Velpatasvir provides pan-genotypical efficacy, good tolerability and limited drug interaction with ART. These characteristics will further enhance the ability of HIV/HepC to be safely and effectively managed in primary care settings within Australia.

HIV Forum—31 May 2017 (11am to 6pm)

I would like to present my interpretation of a session at the HIV Clinical Forum (for integrate inhibitors) held on the 31st May 2017. I believe this sessions was not as widely attended as the first day of the Asia Pacific AIDS and Confections Conference (APACC). Specifically, I will focus on an ‘HIV prevention 2.0’ talk by Dr Charles Boucher, who is a virology professor in Rotterdam and the scientific director (and owner) of Virology Education, Utrecht, Netherlands. Virology Education is the organisation that put together the APACC event in Hong Kong right now and have at least 8 other conferences throughout the year in a number of international locations.

Please note that the information presented here is not exhaustive and is limited by the speed at which I was able to take notes and my individual interpretation.

Dr Boucher began his talk speaking about the HIV prevention methods of circumcision, condoms, PrEP, PEP and ART. I was quite interested in the addition of circumcision to this list, because in my experience it is not often included in such lists. The evidence that male circumcision reduces HIV infections is quite strong.

The cost of prevention methods is a very significant problem across the world and very specifically in developing countries. Dr Boucher commented that governments struggle to understand the medication PrEP and do not see its effectiveness in reducing the cost of HIV ART and associated health care costs. I believe that some of the attendees and presenters have mentioned that PrEP comes at a cost of approximately $1US per day, which is completely unattainable to many persons around the world. Among these people are severely disadvantaged groups such as sex workers, transgender individuals and PWID.

Targeting strategies for each at risk population was a point made repeatedly by this speaker. It is interesting to note that the percentages of specific population transmission routes varied considerably between countries attending this conference. The sexual transmission groups in Australia are dominated by the MSM community whereas in China the most common group transmitting the virus are heterosexuals (66%).

The doctor concluded by saying that increasing annual testing and the uptake of PrEP in the high risk population of MSM is very important. Lack of substantial reductions in transmission is not due to ineffective ART provision or inadequate retention, rather, it is due to frequent early transmission. Dr Boucher seemed dubious as to achieving the goal of zero new HIV infections in 2030 and recommended closer collaboration between public health professionals and HIV health care providers. He also repeated his recommendation of targeted strategies and intervention approaches with specific reference to sexual/virological networks.

NB. I would like to say that the doctor also spoke about flyogenetics, analysis of sequences, resistance genotyping and viraemia but I am unable to accurately represent this information. I am very much looking forward to all of these presentations being accessible online and organisers of this even have informed me that 80% or more of the presentations should be available within 2-3 weeks.

This area was addressed by two speakers, these being Fujie Zhang and Martin Choo. Dr. Zhang is a medical practitioner whilst Mr. Choo is a social scientist.

Both discussed barriers to care from their respective viewpoints and whilst many barriers are common to my practice in Australia; others were alien to me. For instance, all the classes of ARV and the individual medications within those classes are not all available in China. Truvada is a single medication that isn't available. How can PrEP be rolled out if Truvada isn't available? Dr. Zhang didn't elaborate on why this was the case and I suspect the reasons are beyond the scope of this blog. He did mention that there was a need to develop new ways of delivering PrEP so as to ensure people at risk within China (and other Pacific-Asia countries) can access it.

Mr. Choo talked about barriers from a community level. He gave examples of negative experiences endured by HIV positive MSM/Transgender people which he states are not isolated instances in certain S.E. Asia cities where conservative attitudes to non-binary gender/sexuality exist. He spoke about an episode of a breach of confidentiality and made quite an interesting point around the funding of services by NGOs. The point being its all well and good providing money for services, but if there is no infrastructure built in to ensure confidentiality, breaches will happen.

Where is the epidemic heading?

Chris Beyrer opened the conference with his keynote lecture entitled, HIV/AIDS in the Asia Pacific: Where is the epidemic heading?

He told us that there are 5.1 million people living with HIV in the region, this is actually a low prevalence. However, only 41% living with HIV get ARV, which means approximately 3 million of these people don't get access to ARV's. Only Australia provides adequate levels of ARV coverage.

He went on to discuss key populations, these were defined as groups who have a disproportionate burden of HIV and also lack access to services, including:

• MSM (Men who have Sex with Men)
• Sex workers of all genders
• Trans females who have sex with men
• Discordant partners
• Adolescents from all key populations

He went on to tell us that the major strain of HIV has also changed within the region and that a strain predominant in Bangkok is driving the increase in HIV in the Asia Pacific area.

Health as a human right was also touched on with Chris telling us that a low proportion of PWID are receiving ARV. Despite the efficacy of HIV PrEP being proved in 2011, the roll out of this HIV prevention strategy was yet to happen.

Chris discussed how dealing with stigma and discrimination issues is a valubale tool in the fight against HIV. He highlighted how the 'war on drugs' drives PWID underground and this in turn fuels HIV/HCV rates. He drew attention to the appalling treatment of MSM as well as PWID In countries such as Indonesia and the Phillipines. In a bid to end discrimination, UNAIDS has appointed a 'SOGI' (Sexual Orientation and Gender Identity) Officer to monitor rights abuses of the LGTBIQ community. Whether this officer has any powers or impact remains to be seen.

Chris' take home message about fighting HIV in the Asia Pacific region was clear: 'MORE NEEDS TO HAPPEN IN THIS REGION'.