The opening plenary talk was given by Dr Valarie Delpech, who outlined the progress towards attaining treatment for all.

• the UNAIDS target for 2020 is 90-90-90
• 90% of patients diagnosed
• 90% of patients on ART
• 90% with viral suppression
• data from Levi et al (2016) showed
• 54% diagnosed, 41% on ART and 32% virally suppressed (2015 data)
• there appears to be a great disparity in the countries able to achieve this with many having poor rates of diagnosis and hence low rates of treatment/viral suppression
• Dublin declaration data: EU/EEA countries are performing better than the non-EU/EEA
• to date, no country has met the 90-90-90 goal (except claimed by Sweden)
• a major issue
• most countries have very little data about actual rates (even 4 decades into the epidemic)
• there is variation with data sources and quality of definitions/standard methodology

Dr Laura Waters talk on HIV treatment cascade and other HIV population prevention/treatment issues.

2020 goals aiming for 90% of people with HIV diagnosed/90% diagnosed on treatment/90% on treatment undetectable - corresponds to 74% of those with HIV having undetectable viral load.

•  Currently (globally) only 32% of those with HIV are on treatment with undetectable VL.

June 2016 paper (Lazarus et al) on adding a “fourth 90” to the 90-90-90-90 targets; that 90% of those on ARVs with undetectable VL have good health-related quality-of-life. Especially pertinent considering incidence of co-morbidities and ageing HIV-infected population (in developed countries).

2016 research from Toronto (Wilton et al) on high-risk populations and perception of risk studied 420 MSM who were objectively high risk:

•       68.3% didn’t perceive themselves to be at moderate to high risk
•      23.6% unaware of PrEP
•      40.1% unwilling to use prep
•    47% lacked a family physician with whom they could discuss HIV issues

Survey of Glasgow2016 audience on new directions for treatment - 40% of attendees believe that non-oral ART will be first-line by 2026.

Transmitted drug resistance by geographical region (START trial) - Australia highest (17.5% had any transmitted drug resistance)

There’s a particular gentleman at the AIDS 2016 Conference who causes a kerfuffle wherever he goes and I’ve witnessed his performance a number of times over the past few days.

At the end of every session he asks the lecturer “So, what are you doing about TB?”

It’s an AIDS Conference so most speakers are caught off guard when they don’t get a question about AIDS, but on Tuesday a speaker retorted “Well Anton, I didn’t know you were in the room, otherwise I wouldn’t have asked if there were any questions”.

I’m sure you’ll be pleased to hear that Dr Anton Pozniak finally got his own platform to speak in the plenary session.

He informed his captive audience that it’s all very good to treat HIV, but every year in Africa, Tuberculosis causes more deaths. He reminded us that our current TB vaccination is 95 years old and we need a new one.

Tuberculosis is diagnosed too late, with half the diagnoses made at post-mortem. HIV testing is improving, but we also need to be using a rapid test for TB. Whether it’s spitting in a pot or peeing in a jar, we already have the technology to test for Tuberculosis - but we need it to be quick, portable and affordable. 

We know Tuberculosis causes significant morbidity and mortality for people living with HIV (PLHIV). We also know that using Anti-Retroviral Therapy (ART) by itself is not sufficient to treat Tuberculosis. ALL patients co-infected with HIV & Tuberculosis need to be treated by a combination of ART and anti-TB medications.

We cannot shorten the duration of Tuberculosis treatment to any less than 6 months using our current anti-TB medications. New drugs are being trialled and some appear promising, but we’re even trialling old drugs to see if they might possibly work for Tuberculosis too.

Nelson Mandela once said “We can’t fight AIDS unless we do much more to fight TB”, but Anton isn’t keen to stop there. He not only wants to fight HIV and Tuberculosis, but he’s keen to eradicate viral hepatitis too.

Anton's dream is for everyone with viral hepatitis to be treated, but this dream comes with a price.

Hepatitis B treatment costs ~$15,000 in the USA, but the estimated true cost is $36. Hepatitis C treatment in the USA costs ~$84,000, but the estimated true cost is $62. Affordable medication can truly change the lives of millions of people around the world, but that's not yet happening.

Anton urged everyone to communicate and combine efforts to provide integrated health services for people in need. Testing and treatment should not only be for HIV, but also for Tuberculosis, Hepatitis B & Hepatitis C. 

We’re aiming to end HIV by 2030, but let’s aim to eliminate Hepatitis C and Tuberculosis too.

Anton closed his speech by saying that we need new 90:90:90 goals. We should aim for the cost of HIV treatment to be $90 per year, Hepatitis B treatment should be $90, and Hepatitis C cures should be $90 too.

NB - There was no kerfuffle at the end of his presentation as Dr Anton Pozniak wisely did not ask the audience if they had any questions. 

This paper reviewed the increase in viral suppression and sustained viral suppression in USA adults on ART between 2009 and 2013.

Viral suppression increased in a linear fashion from 72 - 80% a significant 2% rise year on year. Sustained virological response followed a similar trajectory from 58% - 68% over the same time. This was not explained simply by an increase in number of people on therapy.

Women, 18-29 year old's, 30-39 year old's, African Americans all had a greater benefit than the overall. MSM were higher than the average at all time points.  There were two Guidelines introduced during the study period which actively promoted treatment and barriers and delays to accessing AIDS drugs. All suggesting that policy change is having impacts.

This is Oral paper number 53, in session O-5, if you want to have a look when the presentations go on-line. http://www.croiconference.org/

 Greetings from Day 1 of IAS 2015,

Treatment as prevention (TasP) and the UN proposed ambitious 5-year treatment target of 90% of HIV+ve individuals being diagnosed, 90% of those diagnosed on efficacious treatments and 90% of those treated virally suppressed equating to 73% of all HIV+ve individual’s being virally supressed was the topic of discussion at the pre-conference workshop UN 90-90-90 Target Workshop: Lessons from the field.

There were four sessions spanning the day. After an opening speech by Michel Sidibé, Session One starting with RCT evidence to support immediate versus standard of care (SOC) ARV population-based roll out interventions and it’s utility to achieve the 90:90:90 target (SEARCH, HTPN071 (POPART), ANRS12249 and the Botswana Combination Prevention Protocol(BCPP). There was also some evidence reported for the utility of financial based incentives (FIs) to encourage linkage to care (HPTN065) and some discussion of acceptability of immediate ARV in sero-discordant couples (HPTN052) though 1-year follow-up results of HPTN052 will be presented Monday 2:30pm. The take home messages of session one included:

• Largely testing rates, linkage to care and viral suppression levels achieved in SEARCH, POPART, ANRS12249, and BCPP were all high, around the 80% mark, however the big question of the impact of early ARV on HIV incidence in all of these trials is yet to be determined. Results so far look promising.
• There still remain some pockets of the HIV+ve population which seem consistently hard to reach, primarily migratory young men in Africa. However while there were some gender disparities in linkage to care, once in care outcomes seemed similar for both genders. More social behavioural data from SEARCH, POPART and ANRS12249 to come.
• There was evidence to support that immediate ARV does not have detrimental impacts on adherence to treatment i.e. HIV+ve people who feel healthy still seem to be good at take their drugs
• The multi-disease approach undertaken by SEARCH, grouping testing for HIV with hypertension and diabetes was an encouraging approach
• Financial based incentives did not show significant improvements in linking known HIV+ve individuals into care in the US, however they did show some efficacy in specific sub-groups, suggesting possibly that FI should be a target rather than a broad roll out. Some discussion over the ethics of FIs and the difficulty in implemented these strategies was highlighted in the discussion

Session Two largely covered evidence from cohorts. Evidence in achieving the 90-90-90 targets was presented for HIV cohorts in rural Malawi, Swaziland, KwaZulu-Natal and Rwanda, and evidence from the new cohort AFRICOS was presented. Lessons from this session included:

• Results from rural Malawi where MSF task shifted ARV roll out from doctors to nurses which was later subsumed into the national program look very promising, 77% diagnosed, 84% on treatment and 91% of those virally suppressed. Again young men are those not linking to care.
• The Early Access to ART for All (EAA) Study in Swaziland provided evidence for scalability feasibility and acceptability of the 90-90-90 target approach. Results supported initiating ARV on the same day as testing to avoid LTFU. While this may be difficult to implement if GART for first line is part of the recommended national guidelines in most of the developing world it is not.  Further lessons from KwaZulu-Natal presented by Frank Tanser showed barriers to care were distance from treatment centres (even in non-centralised settings) and gender.
• The cascade of care in Rwanda looks close to the 90-90-90 target, with the epidemic now moving into older aged groups.

Session Three covered field implementation initiatives in China, Brazil, Thailand, and San Francisco. The ability for faith based organisations to engage people into care was also presented as well as some interesting results from a phylogenetic monitoring system that has been set up in British Colombia. Take home message from this post lunch, slightly jet-lagged session were:

• In many settings described in this session, patients still had a median CD4 at diagnosis of less than 350 so it’s not really a question of immediate or deferred ARV rather engaging people in testing and linking to care. HIV peer intervention testing and self-testing has found to have encouraging results in Brazil. While a mixed facility and community-based testing model has improved diagnosis and linkage rates in Thai MSM and Transgender populations.

• San Francisco has surpassed the 90-90-90 target and is now aiming for zero new infections. The RAPID program which enlisted individuals in immediate same-day ARV initiation looked promising. The difficulties in reaching that last 10% of the HIV+ve population in non-generalised epidemics was highlighted. How to reach specifically transgender populations was also discussed in question time, online outreach methods and linking ARV services with hormone therapy services were some of the suggestions.

• Finally a population-wide HIV resistance database in British Colombia has been used for phylogenetic monitoring of outbreaks in real time. Fascinating results but a real potential for huge legal ramifications (two Supreme Court appearances later, Art Poon and colleagues in British Colombia have managed to resist forced disclosure of individuals). What a shame we live in a world where criminalization of sex in HIV+ve individuals is still common place!

And finally the workshop ending with presentations from donors, PEPFAR and the Global fund, and agencies, CDC who highlighting the cascade in the US, and the WHO and IAPAC who discussed soon to be released guidelines. The main highlight of this session was the (unofficial) report by Gottfried Hirnschall that the new WHO ‘When to Start’ guidelines including PrEP recommendations will likely be released in September of this year. These will (unofficially) include ART initiation for all regardless of CD4 count, PrEP for individuals with substantial risk (to be defined…), Option B+ as the recommended SOC and some suggestions for dose reduction strategies.

So finally, my overall conclusions of the workshop are the 90-90-90 UN target seems a difficult target but potentially achievable in some settings. Primarily generalised epidemics where the health system can support such targets with UNAIDs strengthening the provision of ART and donors getting on board, or non-generalised epidemics where innovation methods are employ and large amounts of resources can be mobilised in support of such efforts.  It will, however, be a specific challenge in other setting where either there isn’t a national health system to support such a roll out or there isn’t the resources to achieve these target where the epidemic remains localised in particularly hard-to-reach populations. As suggested by one of the attendees, perhaps there should be a fourth 90, 90% of countries achieving the 90-90-90 UN target by the year 2020?

For details of the workshop see http://www.treatmentaspreventionworkshop.org, for a live stream of the workshop see http://flash-vs.cfenet.ubc.ca/cfestream1.html