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Friday 27 July 2018

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Progress against HIV in young people lags behind as Africa's youth population grows

Aleya Khalifa at AIDS 2018. ©International AIDS Society/Marcus Rose.

Africa is far off track in reducing new HIV infections among children and young people and is unlikely to reduce new infections in young people substantially before 2030 due to an anticipated doubling of the adolescent population, according to findings from a UNICEF modelling exercise presented at the 22nd International AIDS Conference (AIDS 2018).

The population of people aged 15 to 24 living in sub-Saharan Africa will almost double by 2050 whereas it will decline or remain stable in every other region of the world.

The study found that if current trends prevail, although the number of new infections in children under five years of age will fall by half by 2030, to around 140,000 per year, new infections in adolescents (aged 15 to 19) will not be halved until 2050 and will still be running at a rate of approximately 200,000 per year in 2030.

The model also looked at what might happen if the Fast Track goals for reducing HIV incidence and treatment coverage by 2020 (81% coverage) and 2030 (90% coverage) are achieved. The impact of achieving these goals would be most pronounced for new infections in adolescents. Whereas on the current trend, new infections among adolescent girls would fall by 42% by 2030, new infections would fall by 83% by 2030 if 90% treatment coverage could be achieved.

But the study also found that countries are far from reaching the 2020 targets, let alone the 2030 targets, implying that the ‘current trend’ scenario is highly likely to play out unless major efforts are made to reach adolescents and prevent new infections in children.

Ending HIV in gay men: what is working?

Valerie Delpech at AIDS 2018. Image credit: @Paul_Steinberg

Substantial decreases in HIV diagnoses in key cities show the way to elimination of new HIV diagnoses in gay men, a workshop at the AIDS 2018 conference heard this week.

Public health officials, clinicians and community leaders presented data from Sydney, London and New York, which all showed remarkable declines in new HIV diagnoses amongst gay men. Yet each city also highlighted groups which had benefitted more and less from this decline, giving clues to ways in which a combination prevention programme could be optimised and targeted.

Key factors the cities shared included increased rates of testing; testing campaigns; improved real-time data flow and quality; stakeholder engagement, including clinics and communities; earlier treatment access and availability of pre-exposure prophylaxis (PrEP). Political leadership at all levels was also highlighted.

Civil society under threat

Peter Sarosi at AIDS 2018. Image credit: @sarosip

Civil society organisations (CSOs) providing HIV services and advocacy to key populations and people living with HIV are increasingly under attack from populist and repressive government regimes across the world, delegates to the AIDS 2018 conference were told.

Speakers from Hungary, Russia, Venezuela, Kenya and the Philippines outlined ways in which they were facing not just financial cutbacks but government interference in their attempts to tackle HIV and support men who have sex with men, people who use drugs, sex workers and other vulnerable populations.

Peter Sarosi of Rights Reporter Foundation spoke of the rapid reductions in civil liberties under the Orbán regime in Hungary. Both there and in Russia and Kenya, CSOs receiving external donor funding are required to register as 'foreign agents', which carries a social stigma and discourages others from collaborating with them. The Hungarian drugs strategy no longer supports harm reduction and the two main needle exchanges in Budapest have been forced to close.

Alberto Nieves of Acción Ciudadana Contra el SIDA described a rather different situation in Venezuela, where the country is facing a complex emergency of political and economic origin. The health system is in chaos and it has gone from having the best HIV treatment programme in Latin America to having none, leaving people with HIV at risk of death.

Saoyo Tabitha Griffith, a lawyer, described the situation in Kenya, where CSOs cannot operate unless they are registered. Deregistration is common and some organisations have been refused registration, particularly those supporting LGBT communities. To defend Kenyan CSOs, international scrutiny had been helpful, particularly from the UN.

First randomised HIV cure study fails to eliminate infected cells

Richard Jefferys and Sarah Fidler at AIDS 2018. ©International AIDS Society/Steve Forrest/Workers' Photos

One study whose results were eagerly awaited at this year's International AIDS Conference was the RIVER study.

This was the first study to add to standard HIV therapy a vaccine-plus-drug regimen intended to reduce the number of dormant immune-system cells that harbour HIV – the so-called HIV reservoir.

One of the strategies researchers have been considering as a pathway towards a complete cure for HIV has been the so-called 'kick and kill' strategy. The hypothesis behind this is that it is the invisibility of the reservoir cells that is the problem. If they were active and became visible to the immune system, it would start to pick them off, and the reservoir of HIV would start to shrink.

A therapy that could produce significant enough reductions in the reservoir could produce a remission or cure for HIV.

In short, the RIVER study did not produce the result hoped for: it did not reduce the amount of cells in the body containing HIV genes. It did stimulate an anti-HIV response, and it did cause some of the cells containing HIV to become active and therefore in theory visible to the immune system, but those two effects did not link up to kill off HIV-infected cells.

Supervised drug consumption sites offer opportunities for hepatitis C testing and treatment

Activists at the Towards Zero Together march in Amsterdam. Photo by Liz Highleyman.

Most supervised drug consumption facilities offer hepatitis C virus (HCV) testing and referrals, but very few offer treatment, indicating that they could potentially play a greater role in curbing transmission and negative health outcomes related to hepatitis C, the conference heard this week.

HCV, hepatitis B virus (HBV) and HIV are readily transmitted through shared drug injection equipment, and there are high rates of these infections among people who inject drugs.

The advent of highly effective and well-tolerated direct-acting antivirals offers the opportunity to expand hepatitis C treatment.

Drug overdose is also a growing concern, worsened by the introduction of fentanyl and other opioids that are much stronger than heroin. Drug consumption rooms, known in some countries as supervised injection facilities, allow people to use drugs under the watch of trained staff, who can administer naloxone (Narcan) if needed to reverse opioid overdoses. There are currently around 100 drug consumption rooms around the world, most of them in Europe.

Eberhard Schatz of De Regenboog Groep in Amsterdam presented findings from a study looking at what kinds of hepatitis C testing, treatment and other health and support services are provided by nearly 50 drug consumption facilities.

Two-thirds of the sites offered onsite hepatitis C testing and pre- and post-test counselling. A quarter of the sites offered liver health monitoring. However, just two sites provided hepatitis C treatment onsite.

The researchers concluded that drug consumption rooms, "Should be considered as a low-threshold HCV treatment provider for people who inject drugs on the community level; innovative arrangements should be sought."

Kaposi's sarcoma remains a concern for people with HIV

Slide from Elizabeth Chiao's presentation of the US study.

A small proportion of people living with HIV continue to develop Kaposi's sarcoma (KS), a cancer linked to immune suppression, according to studies presented at the AIDS 2018 conference this week.

Kaposi's sarcoma, once frequently seen among people with very low CD4 counts, decreased dramatically with the advent of effective antiretroviral therapy (ART). However, it remains the most common AIDS-defining cancer.

One analysis presented at the conference, based on data from France, found that some people develop new KS or experience KS recurrence even after they start taking ART and see a rise in their CD4 count. Nearly half the people in the study who were diagnosed with KS had a CD4 count over 500; only 19% had a CD4 count below 200.

A second study observed a pocket of higher KS prevalence among African-American men in the US south. Asked to speculate about the reasons, presenter Elizabeth Chiao suggested that black men in the south, especially young men, may have less access to HIV testing and other care.

HIV outbreaks in people who inject drugs

Since 2011, there have been outbreaks of rapid HIV transmission among people who inject drugs in Athens, Bucharest, Dublin, Glasgow, Luxembourg, Tel Aviv, Saskatchewan (Canada) and Scott County (Indiana, USA).

They have all occurred in settings where sufficient resources should be available to prevent outbreaks, a group of public health officials reported at AIDS 2018.

Combination prevention for people who inject drugs consists of needle and syringe programmes, opioid substitution therapy and HIV treatment. In settings where combination prevention has been implemented at scale, it has prevented epidemics.

The largest outbreaks have been in Bucharest and Athens, with around 1100 new infections at each site.

Very few harm reduction services were available in Athens. In Scott County, providing needle and syringe exchange was illegal, while opioid substitution therapy and HIV treatment were not locally available. Due to the Global Fund’s withdrawal from Romania, many needle and syringe programmes had closed down in Bucharest.

In each outbreak setting, public health bodies have expanded the availability of prevention interventions, but complete coverage has not always been achieved.

The authors stress the importance of achieving high coverage of combination prevention, maintaining it, and adapting services in response to changing patterns of drug use. They say, "Complacency for HIV prevention is emerging as an important threat to the success of combined HIV prevention for people who inject drugs.”

HIV linked to higher risk of heart failure

Alan Go at AIDS 2018. Photo by Liz Highleyman.

Having HIV is associated with a significantly increased risk of developing heart failure, but the reason is not yet clear, according to a presentation at the AIDS 2018 conference yesterday.

Many studies have looked at cardiovascular disease among people living with HIV, usually related to the development of atherosclerosis and coronary artery disease, which can block blood flow and lead to heart attacks and strokes. It is well known that HIV infection is associated with an excess risk of atherosclerotic cardiovascular events.

This research instead focused on heart failure, or the inability of the heart muscle to adequately pump blood, which has not been extensively studied.

The research team looked at heart failure and its possible contributing factors in people living with HIV in Northern California, Southern California and the US mid-Atlantic states between 2000 and 2016. They identified all eligible patients without prior heart failure, matching them 10-to-1 with HIV-negative people. The final study population included 38,868 people with HIV and 386,586 HIV-negative participants.

People with HIV had a significantly higher rate of heart failure than HIV-negative participants, despite having fewer cardiovascular risk factors, and the researchers concluded that heart failure among people living with HIV does not appear to be related to atherosclerosis pathways, or build-up of plaque in the arteries.

Scientific analysis from Clinical Care Options

Clinical Care Options (CCO) is an official online provider of scientific analysis for the conference.

Their coverage will include capsule summaries of important clinical data, downloadable slides and expert faculty commentary on key HIV prevention and treatment studies.

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