Looking to the future - HIV in 2031

In 2031 it will be 50 years since the first cases of AIDS were reported.  It was predicted at the International AIDS Conference in Mexico City yesterday that there could be over 80 million HIV infections by then.

Peter Piot, the executive director of UNAIDS, expressed hope that by 2031:

• Everyone at risk of HIV would know their HIV status.
• There would be long-lasting first- and second-line treatment combinations that had few side-effects and worked against drug-resistant virus.
• HIV drugs would be appropriately used for prevention.

Because it would be difficult to provide treatment to so many people, delegates were told that there needs to be more research into ways of eradicating HIV or - at the very least - into finding a way of containing it so people living with HIV would not require treatment for life.

Massive investment will be needed to ensure that there is enough money to pay for HIV drugs. It was suggested that international donors would need to think in terms of “pension-fund” provision, to make sure that there is enough money to pay for treatment.

HIV treatment and prevention

There is enough evidence to show that wider use of HIV treatment will mean fewer new HIV infections. That was a consistent message from speakers at the International AIDS Conference.

Prof Julio Montaner, the incoming president of the International AIDS Society, which organises the conference, said: “We believe that there is now enough evidence to say to policymakers that if you roll out HIV treatment with 100% coverage, you will see a reduction in HIV transmission.”

There is a lot of scientific evidence to support this statement. For example, HIV transmissions in Taiwan fell by over 50% after HIV treatment was introduced.

HIV transmissions fell by 90% in Rakai, Uganda thanks to the provision of HIV treatment. This was combined with adherence support to make sure that patients had an undetectable viral load and received safer sex counselling.

And it was recently predicted that two-thirds of new HIV infections in the Canadian province of British Columbia would be prevented over the next 20 years if every person with HIV started treatment when their CD4 cell count was around 350.

It has also been predicted that the HIV epidemic would be halted within 50 years if every person with HIV was given anti-HIV drugs.

Suggestions that the increases in new HIV infections amongst gay men in many western countries were due to complacency and the availability of treatment were dismissed. There was a lot of evidence to show that large numbers of these new infections were originating in undiagnosed individuals, many of whom were recently infected with HIV.

A trial is underway to see if starting treatment at CD4 cell counts above 350 would cut HIV transmissions in couples where one of the partners is HIV negative. The latest British HIV treatment guidelines say that starting treatment at higher CD4 cell counts could be considered for patients with an HIV-negative partner. However, they add that treatment is not a replacement for safer sex.

Combination prevention needed

But the conference was also told that there was no “magic bullet” for HIV prevention.

Rather, “combination prevention” is needed, that includes:

• Condom use and fewer sexual partners.
• Circumcision and the prevention of mother-to-child transmission.
• Treatment, not just of HIV but also of other sexually transmitted infections.
• Social policies to fight poverty and defend human rights.

The conference also heard that India has reduced the number of new HIV infections in female sex workers and men who have sex with men.  Condom use was increased and rates of sexually transmitted infections fell.

Tenofovir and kidney problems

A small number of people taking the anti-HIV drug tenofovir develop kidney problems. Research presented to the Mexico City conference has found that these are linked to taking those blood-pressure medications that can also cause kidney problems and also taking protease inhibitors.

Tenofovir (Viread) is a first-choice anti-HIV drug and is in the combination pills Truvada  (with FTC) and Atripla  (with efavirenz and FTC). It seems to be a safe drug, but a small number of people have developed kidney problems after starting treatment with it.

Having high blood pressure can cause kidney problems. It is also known that people of African race have an increased risk of kidney disease.

The American researchers found that the risk of kidney problems in patients taking tenofovir was increased if they:

• Had high blood pressure.
• Were taking other drugs that can cause kidney problems.
• Were also taking a protease inhibitor.
• Had a history of HIV-related illness.

Rates of kidney disease were much lower in patients taking tenofovir with an NNRTI.

IL-2 can increase CD4 cell count, delaying the need for treatment

Interleukin-2 (IL-2) occurs naturally in the body and it plays a key role in stimulating the immune system, triggering the creation of CD4 cells.

New research shows that injections with IL-2 can increase CD4 cell count. The study involved people whose average CD4 cell counts were 380 - just above the level where HIV treatment is recommended.

The researchers divided these patients into two groups. One group was given injections of IL-2 twice for five days every eight weeks, the other received no treatment.

CD4 cell count increased by an average of 50 cells in the people given the IL-2 injections, but fell by over 60 cells in the patients who did not receive them – below the level where HIV treatment is recommended.

The researchers calculated that the increases in CD4 cell count they saw could delay the need to start HIV treatment by up to two years.

Side-effects of IL-2 treatment include flu-like symptoms, but none of the patients stopped treatment with the drug because of them.

Urine test to predict heart problems

New research shows that a urine test can be used to see if a person with HIV has a risk of heart disease.

Earlier studies have shown that people with HIV can have an increased risk of heart problems, so it is important to have simple tests to ensure problems can be spotted early and treatment provided.

A small American study involving people taking successful HIV treatment showed that levels of certain substances in urine were related to well known risk-factors for heart disease, such as high levels of “bad” cholesterol.

Further news on aidsmap.com

Two new treatments look promising:

Immune cells extracted from individuals and then modified enhance the individual immune response to HIV infection, and appear to be a safe and feasible approach to HIV treatment, according to several reports this week at the XVII International AIDS Conference.

Conference webcasts and expert commentary

Watch conference webcasts

Online coverage of the XVII International AIDS Conference provided by kaisernetwork.org, a free news and information service of the Kaiser Family Foundation.

Expert commentary podcasts from AIDS 2008

Clinical Care Options is proud to partner with the International AIDS Society to provide official online scientific conference coverage of AIDS 2008. HIV experts from around the world will provide analyses of the new data in five clinical tracks and direct the creation of downloadable slidesets. Online coverage includes video and audio highlights in which experts recap the data presented at key clinical sessions, Capsule Summaries of important studies, and more. Visit Clinical Care Options for your free membership and subscription to HIV email updates and podcasts.

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