News from CROI 2019
The Conference on Retroviruses and Opportunistic Infections (CROI), recently held in Seattle, is the most important HIV conference of the year. This edition focuses on the top news from CROI for people living with HIV in the UK and in comparable countries.
Injectable HIV treatment
A combination of two injectable anti-HIV medications taken once monthly had a very low rate of treatment failure and a favourable safety profile, according to results from two phase III trials presented at the conference.
The injections contained cabotegravir (an integrase inhibitor) and rilpivirine (a non-nucleoside reverse transcriptase inhibitor). These injectable drugs haven’t yet been approved by regulators, but probably will be in the next year or two. They will probably be the first antiretroviral medications ever to be licensed for long-acting use – in other words, not needing to be taken every single day.
Before beginning the injections, you need to take these same drugs as daily pills for a month. This is a safety measure, in order to check that you do not have a bad reaction to the drugs (you can quickly stop taking a daily pill, but once you’ve had an injection the drug stays in your body for several weeks).
After that, you go to a clinic to have the injections, given in the buttocks, once a month. In most countries, people will need to visit an HIV clinic in a hospital for the injections, but it might be possible to have the injections at a primary healthcare clinic or a pharmacy, which could be more convenient.
In one study, people were taking HIV treatment for the first time. In the other, they were switching from an existing combination of oral pills. The researchers followed people for just under a year.
In both studies, only 2% or less of people were recorded as having a viral load above 50 copies/ml. Laboratory analysis showed that drug levels in the blood were similar to levels achieved with pills.
Around 20 to 30% of people found the injections painful the first few times they were given, but most people got used to them. They expressed a high level of satisfaction with monthly injections compared with daily pills, and nearly all said they would prefer to use the injectable method. Many said they liked not being reminded of HIV each day or not feeling the need to hide tablets from people around them.
Big drop in hepatitis C in gay men in London
The drop is due to regular testing for hepatitis C (which picks up infections early) and more people taking modern hepatitis C treatments. It shows that for hepatitis C – as for HIV – “treatment is prevention”. Once people have had successful hepatitis C treatment, the virus is cleared from their body, so there is no infection risk for anyone else.
When the study began in 2013, not many people started hepatitis C treatment promptly, because they did not want to take the old treatment with injections or because there were restrictions on access to modern treatments. This waiting time probably led to onward transmission of the virus.
But since 2016, most men diagnosed with hepatitis C at the clinics in the study (Mortimer Market Centre, St Mary’s and the Royal Free) have started treatment within a year of their diagnosis.
"Our study has shown that greater access to new treatments, closer monitoring and screening can greatly reduce hepatitis C cases,” Dr Lucy Garvey of Imperial College Healthcare told the conference.
Most NHS clinics now offer hepatitis C treatment at any stage of liver disease, but they do not usually allow people to start treatment in acute infection (the first six months, during which some people will clear the virus naturally) or a second course of treatment for those who are infected a second or third time.
However, all three clinics in this study offered clinical trials that provided treatment without these restrictions. So the figures are probably not representative of what’s happening across the UK – but do show what is possible.
For more information, read NAM's booklet 'HIV & hepatitis'.
Is a London man the second person ever to be cured of HIV?
A London man who had been living with HIV for over a decade no longer has any traces of the virus in his body after undergoing a bone marrow transplant to treat cancer. He stopped taking anti-HIV medications a year and a half ago.
This is only the second reported case of an adult apparently becoming free of HIV infection. The first case, Timothy Ray Brown, known as the 'Berlin patient', was reported 12 years ago and involved a similar procedure. Brown was at the conference in Seattle and told NAM’s reporter that he was excited to hear that another person may have been cured of HIV. “I consider him my sibling and I can’t wait to meet him,” he said.
In both cases, the procedure was only done because the men needed bone marrow transplants for life-threatening blood cancers. Their doctors selected donors who lacked a cell-surface molecule called CCR5, which allows HIV to bind to certain cells and infect them. People who don’t have it are almost totally resistant to infection with HIV.
The London man’s transplant led to complete remission of his cancer but also seems to have cleared HIV from his body. For the moment Professor Ravindra Gupta of University College London, who presented the case, is cautious about describing it as a ‘cure’. The man has only been off HIV treatment for 18 months and his HIV could still reappear.
Some media outlets have talked about a third person cured, but that person only stopped taking treatment four months ago, so it is far too early to tell.
Does this change anything for people living with HIV? Not now. Bone marrow transplant is a life-threatening procedure in itself. The gruelling treatment would not be right for someone who did not have cancer. Furthermore only one in a hundred transplant donors have the rare genetic mutation that is needed and some other attempts to try this procedure have failed.
But the case does show that Timothy Ray Brown was not a one-off. It is a proof of concept that manipulating the CCR5 receptor could be a potential path to an HIV cure.
Integrase inhibitors and weight gain
More evidence that HIV treatment with integrase inhibitors is associated with weight gain, and that people gain more weight after beginning treatment with an integrase inhibitor than people taking other drug classes, was presented at CROI.
Putting on a little weight after starting HIV treatment is a common event, especially if you were unwell beforehand. It’s often called a 'return to health' weight gain.
But it seems that medications from the integrase inhibitor class cause additional weight gain. This class of anti-HIV medication is extremely effective and is recommended as a preferred option for first-line HIV treatment in many countries. Four integrase inhibitors are approved for use in people living with HIV: raltegravir (Isentress), dolutegravir (Tivicay, also in Triumeq and Juluca), elvitegravir (in Stribild or Odefsey) and bictegravir (in Biktarvy).
The North American AIDS Cohort Collaboration found that among 24,001 people starting treatment for the first time, treatment with an integrase inhibitor was associated with greater weight gain than treatment with a non-nucleoside reverse transcriptase inhibitor (NNRTI). After five years on treatment, people taking an integrase inhibitor had gained a median of 6kg, compared to 4.3kg for people who started an NNRTI.
Two smaller studies also found an association between integrase inhibitor treatment and weight gain, and one other study found no association.
U=U is a human rights issue
“All people living with HIV have a right to accurate information about their social, sexual and reproductive health,” Dr Carrie Foote told a symposium on Undetectable = Untransmittable (U=U) at the conference. Foote has been living with HIV since 1988 and is one of the founding members of the U=U campaign, which aims to communicate the finding from a series of studies that HIV-positive individuals on successful treatment cannot pass on HIV to their sexual partners.
For people living with HIV, U=U has the potential to transform their social, sexual and reproductive lives while also working to dismantle stigma. “Stigma is killing us,” Foote added. “HIV stigma is a public health emergency and U=U is an immediate and effective response to begin to dismantle stigma.”
The symposium highlighted issues relating to U=U including the language that healthcare providers should use when talking about an undetectable viral load and how doctors should deal with some of the more complex questions around U=U. These include advice on viral load blips, missed doses, and breastfeeding.
For more information, read NAM's factsheet 'Undetectable viral load transmission'.
Editors' picks from other sources
from The Economist (requires free registration)
The sexual-health pioneer and campaigner for access to PrEP was 44.
from The New York Times
Strategies abound to end the AIDS epidemic, but expense – mostly for drugs costing up to $50,000 a year – is the inevitable obstacle.
from The Guardian
One of five men infected by hairdresser Daryll Rowe, Royal’s own diagnosis came after both his parents died of AIDS. He explains why he waived his anonymity to talk about the case.
from The New York Times
The news about a second person who may be free of the infection is a distraction from the work we need to keep focusing on.
from The Guardian
Campaigners who want to see HIV PrEP made similarly available elsewhere in the UK say that Scotland’s initial success “puts England’s sluggish delivery to shame”.