Summaries of the news from the 19th Conference on Retroviruses and Opportunistic Infections held in Seattle last month. For full news reports and references to the original sources, visit www.aidsmap.com/news.
Serosorting works – up to a point
Serosorting – restricting unprotected sex to partners with the same HIV status – does work as a prevention strategy in HIV-negative gay men, a study found, but not as well as other strategies, such as using condoms or being monogamous.
Researchers looked at the HIV infection rate in 12,705 gay men who had signed up to four large HIV prevention trials between 1995 and 2007. It found that men who practised serosorting were infected half as often as men who used no HIV prevention strategy (51% efficacy). This was however only half as effective as attempting to use condoms 100% of the time (74% efficacy) and less than a third as effective as always taking the insertive, top role in anal sex.
The most effective strategy was having a monogamous relationship with another HIV-negative man, regardless of condom use, which was six times more effective than serosorting (92% efficacy).
For the full news report see: www.aidsmap.com/page/2287223
Which drugs to use in Africa?
First-line HIV treatment in resource-limited countries has been based on the non-nucleoside (NNRTI) drugs, plus the nucleoside (NRTI) ones. One study from the Democratic Republic of the Congo suggests using protease inhibitors (PIs) with NRTIs may make more sense, because if treatment fails people are less likely to have drug resistance, and will have a wider choice of second-line combinations.
The trial found that while an equal proportion (63 to 64%) of people had undetectable viral loads after a year of treatment, only half as many patients taking boosted lopinavir (Aluvia in Africa, Kaletra in the UK) had actual treatment failure, compared with patients on nevirapine (Viramune), though more people on lopinavir dropped out of the study, leading to equal undetectability rates.
Lopinavir also caused less drug resistance: 85% of people who experienced treatment failure on nevirapine had resistance to it and 75% to at least one NRTI; this compares with no PI resistance and 20% NRTI resistance in people who experienced treatment failure on lopinavir.
For the full news report see: www.aidsmap.com/page/2284972
Superinfections as common as first ones
The rate at which people with HIV acquire second, subsequent infections of HIV (so-called superinfection) is little different from the incidence rate for first infections, studies from Kenya and Uganda show. In the Ugandan study, one in 40 people in the community acquired HIV every year (annual incidence 2.51%), and one in 70 people who already had HIV subsequently caught a second strain.
In the Kenyan study, in a higher-risk population of sex workers, the figures were one new infection a year in every 31 HIV-negative women and one superinfection a year in every 33 HIV-positive women. The studies show that having HIV confers no immune protection against additional strains; this finding has implications for vaccine design.
Although there was no evidence that superinfection had any health consequences, more research is being done to find out if it does.
For the full news report see: www.aidsmap.com/page/2282167
Dolutegravir looks good
The new once-daily integrase inhibitor dolutegravir (DTG) is at least as good as the standard-of-care drug efavirenz (EFV, Sustiva) in suppressing HIV in people new to therapy.
After 22 months on treatment, 78 to 88% of people taking DTG (trialled at three different doses) had undetectable viral loads, compared with 72% on EFV, though this difference was not statistically significant.
Fewer side-effects were associated with DTG: one in nine patients had side-effects classed as moderate or severe on DTG, compared with one in four patients on EFV. Dolutegravir once a day thus looks as potent as the only licensed integrase inhibitor, raltegravir, which has to be taken twice a day. However, dolutegravir will have to be taken twice a day by patients with extensive drug resistance.
For the full news report see: www.aidsmap.com/page/2281387
Treatment cuts infection rate in Africa
A study from South Africa provides evidence that treating a high proportion of the HIV-positive population can cut infection rates in resource-limited as well as in rich countries.
The study was from rural KwaZulu Natal, where one in four adults has HIV and 70% are diagnosed, a high proportion for Africa. Since 2004, the proportion of diagnosed HIV-positive people on treatment has increased from under 10% to over 40%, and over 60% with a CD4 count under 350 cells/mm3.
Once more than 30% of the positive population was on treatment, the HIV infection rate among the community at large halved, from about one infection per 45 people a year to one per 80 people. This study follows similar ones from San Francisco and Vancouver that suggest a link between treatment and prevention.
For the full news report see: www.aidsmap.com/page/2287053
HIV risk and contraceptives
Last year, a seven-country study from Africa found that women who used hormonal contraceptives were twice as likely to catch HIV and, if already HIV-positive, twice as likely to infect partners.
This study produced consternation in the world of HIV treatment and prevention, as it implied a dilemma: would more lives be saved due to less HIV if women stopped using hormonal contraceptives, or would more be saved if they kept using them and had fewer deaths in childbirth?
A new study has found a much weaker association between hormonal contraceptive use and HIV. It found no link between oral contraceptives and HIV infections. It did find that women using injectable contraceptives were 37% more likely to acquire HIV but once behavioural factors – such as the fact that women using injectables were less likely to use condoms – were accounted for, this became a 16% greater risk, which was no longer statistically significant.
For the full news report see: www.aidsmap.com/page/2279470
PrEP: adherence is everything
Adherence rates explain the differences reported in the efficacy of PrEP (pre-exposure prophylaxis) seen in different trials.
Efficacy rates reported from different studies in the last two years ranged from zero in FEM-PrEP (a study among 2056 women) to 75% in Partners PrEP (a study in 4758 HIV-serodiscordant couples). How could giving HIV-negative people antiretrovirals have no effect in one study, yet prevent three out of four HIV infections in another?
Two studies showed that, although participants in both studies claimed high rates of adherence (95% in FEM-PrEP and 97% in Partners PrEP), measuring drug levels showed that fewer than 40% of the women given Truvada in FEM-PrEP had actually taken it in the last two days. In contrast, the true adherence rate in Partners PrEP was over 80%. Another study, of the gay men’s PrEP study iPrEx, showed that four or more doses of PrEP per week would be sufficient to provide near-complete protection against HIV.
For the full news report see: www.aidsmap.com/page/2278778
New tenofovir is more potent
A new version of the drug tenofovir (Viread) that reaches higher levels inside cells than standard tenofovir produced greater drops in HIV viral load after eleven days of therapy.
A study compared a dose of tenofovir with three different doses of the new tenofovir prodrug GS-7340, which is chemically different from tenofovir but is converted to it in the body. After eleven days, GS-7340 produced a 29-fold and 56-fold drop in viral load in patients given 25mg and 40mg doses respectively, compared with a 9.3-fold drop in patients on tenofovir. Patients taking 25mg of GS-7340 had a quarter as much tenofovir in their blood than patients taking the standard drug, but seven times more in their cells. Lower blood levels may mean that GS-7430 causes less kidney damage, the most serious side-effect of tenofovir.
Manufacturers Gilead said they will look at substituting GS-7340 for tenofovir in their four-drug ‘Quad’ pill, which also contains elvitegravir, a new integrase inhibitor: in another study, this combination pill suppressed HIV at least as well as the triple-drug tablet Atripla.
For the full news report see: www.aidsmap.com/page/2280627
Keeping mothers in care is the challenge
Giving HIV-positive, pregnant women combination antiretroviral therapy (ART) regardless of CD4 count results in fewer infections of their babies, one study found, but it also showed they were more likely to be lost from care than women given short-course prevention therapy for 24 weeks of pregnancy and a week afterwards.
Nearly 20% of the babies born to mothers given short-course therapy became infected with HIV, compared with fewer than 6% of those born to mothers on ART. But there were higher drop-out rates in women continuing on ART; in the six months after giving birth, 12% were lost to care, compared with 8% who had taken short-course therapy.
Another study from South Africa compared death and attendance rates of women diagnosed with HIV – some in pregnancy and others when not pregnant – and found higher death rates in non-pregnant women (9 versus 3%) but higher drop-out from care in pregnant women (11 versus 19%). Researchers were unsure why pregnant women disappeared from care; it may be that they feel they can do without treatment or because they tend to be younger and have competing obligations.
For the full news report see: www.aidsmap.com/page/2280032
PEPFAR prevents one in six deaths
The death rate in African countries receiving funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR) is 16% lower than it would have been without PEPFAR, a study shows.
Eighty-five per cent of these deaths would have been due to HIV but some non-HIV-related deaths were also avoided. PEPFAR contributes over half of all the international development money spent on HIV, but focuses most of its resources on 15 ‘focus countries’ that between them contain 50% of the people with HIV in the world. Researchers compared all-cause death rates in eight African focus countries with 18 countries with similar economic profiles. They found that, while annual mortality was a steady 0.75% a year in non-focus countries between 2004 and 2008, it fell to 0.4% in the focus countries during the same period.
The fact that PEPFAR reduced deaths from all causes answers criticisms that, by throwing disproportionate amounts of money at HIV, programmes such as PEPFAR and The Global Fund were starving health systems of resources to fight other diseases such as malaria or infant diarrhoea.
For the full news report see: www.aidsmap.com/page/2280405
Brain impairment improves on ART
Studies on neuro-cognitive (brain) problems provided mixed news. A US study of providing antiretroviral therapy (ART) early to men diagnosed with HIV found that neuro-cognitive performance continued to decline in untreated patients – particularly fine motor skills – but reverted to normal in men given ART.
A linked brain-scan study found that two chemicals, choline and myoinositol, which indicate immune over-activation in the brain, increased slowly in untreated patients over time, but that levels stabilised in people on ART. However, a UK study measuring a protein that attaches to inflamed immune cells in the brain found that even in subjects on ART there were unusual levels of inflammation in parts of the brain that control memory, attention and decision-making.
A study from the US showed that sensitive psychological tests that can detect almost unnoticeable slowness in performance can predict later deterioration. Another showed that neuro-cognitive decline was strongly associated with diabetes and central fat accumulation, while a study from Italy found that low levels of HDL or ‘good’ cholesterol were associated with brain impairment.
For the full news report see: www.aidsmap.com/page/2283344
Treat everyone, say US guidelines
The opening line of the new HIV treatment guidelines released by the US Department of Health and Human Services (DHHS) declares that “antiretroviral therapy (ART) is recommended for all HIV-infected individuals”.
The guidelines marshal a range of studies that show that measurable viral load at any CD4 count is associated with a higher risk of death and illness, and higher rates of cancer and heart disease. This blanket recommendation widens the gap between the US guidelines and the UK guidelines issued by BHIVA (currently in draft form after public consultation), which contain a general recommendation to start treatment at a CD4 threshold of 350 cells/mm3. BHIVA concluded there was no convincing evidence of either clinical harm or benefit to people given ART at higher CD4 counts.
The BHIVA guidelines do, however, recommend treatment for people at higher CD4 counts who have early infection, hepatitis B or C, or a number of other conditions. Both guidelines recommend that the prevention benefits of treatment are discussed with patients but, while the US guidelines recommend that ART is prescribed to “all patients at risk of transmitting HIV to their partners”, the UK guidelines make it the patient’s decision and say that if, after discussing prevention with a doctor, they wish to start therapy, ”this wish should be respected”. It is estimated that only 51% of people diagnosed with HIV in the US regularly access care, compared with nearly 90% in the UK.
For the full news report see: www.aidsmap.com/page/2295568
News picks from other sources
As well as writing our news reports, our team of editors regularly select news from other sources for the news pages of our website. Here is a small selection of recent examples. For more of these, visit www.aidsmap.com/news
Teenagers born with HIV tell of life under society’s radar
HIV-positive youngsters who were infected before or at birth reveal their secret lives. For the full news report, see The Guardian website: http://bit.ly/HxgtAV
Reminders by text messages help HIV patients stick to antiretroviral drug therapy
Mobile phones could play a valuable role in helping HIV patients to take their medication every day, according to a new Cochrane Systematic Review. For the full news report, see Medical News Today: http://bit.ly/H1D4o0
My Grindr experiment
“I started wondering last weekend what kind of responses someone would get if their Grindr profile said that they were HIV+.” See UK Positive Lad’s blog: http://bit.ly/HoedKo
Law on condoms threatens tie between sex films and Los Angeles
Since the early days of X-rated films, this city’s San Fernando Valley has been the industry’s home. With year-round sun, access to Hollywood filmmaking expertise and beautiful young people flocking to the region from around the country, pornographic studios have filmed thousands of movies here each year. For the full news report see The New York Times website: http://nyti.ms/H6R4fF