Final words on Toronto
I’m on holiday this week, so am unable to prepare the normal weekly news digest. In my final hour or so before leaving the office for a week of lying on the beach and walking round Roman ruins, I thought I’d pull together my highlights from last month’s International AIDS Conference in Toronto.HIV treatment
The last time Canada hosted a major international HIV conference was in Vancouver in 1996. This meeting heralded one of the major medical breakthroughs of the 20th century – potent and effective anti-HIV therapy.
Well, this year’s Toronto conference couldn’t compete in terms of excitement and drama, but the research presented to the delegates indicated that doctors and investigators are continuing to refine their use of anti-HIV therapy.
It may be becoming a little clearer what drug should form the basis of first-line anti-HIV treatment. In the UK, it’s recommended that people who are starting treatment for the first time should do so with a combination that includes two nucleos(t)ide reverse transcriptase inhibitors (NRTIs), plus either the non-nucleoside reverse transcriptase inhibitor, efavirenz (Sustiva) or the boosted protease inhibitor Kaletra (lopinavir/ritonavir). But a head-to-head comparison between these two combinations presented in Toronto showed that patients who took the efavirenz-based combination had better suppression of viral load in the longer term.
Anti-HIV treatment means a longer, healthier life, but it also has its problems, including side-effects, adherence, and cost. Because of this doctors and researchers have been interested in the possibility of providing intermittent anti-HIV treatment.
But a major trial looking at treatment interruptions was the SMART study. It was the largest HIV clinical trial ever, involving over 5,000 people in several countries. Patients were randomised to either a treatment conservation arm (discontinue anti-HIV therapy once their CD4 cell count reached 350 cells, and recommencing therapy when it fell to 250), or to continue to take their anti-HIV therapy without interruption. The study was stopped early on safety grounds after it was established that patients in the treatment interruption arm were significantly more likely to become ill or die.
Not only that, but people in the SMART study who took a break from treatment had worse quality of life than people who took HIV treatment all the time.
Another strategy being explored is providing HIV treatment all the time, but with fewer drugs. HIV treatment normally consists of at least three drugs from two of the different classes of antiretroviral drugs.
People who have managed to get an undetectable viral load using this approach may be able to switch to treatment with just one drug – the boosted protease inhibitor, Kaletra . Several studies were presented to the conference on the safety and effectiveness of this treatment strategy showing that for many patients it can be as effective as triple drug therapy in the longer term.
Even though many patients manage to maintain an undetectable viral load in the longer-term, more and more people are running out of HIV treatment options and are in need of new drugs. Progress is being made with new classes of anti-HIV drugs and studies showed that TNX-355, vicriviroc, maraviroc, and MK-0518 could be important new treatment options, particularly for people who have taken a lot of HIV drugs before.
But before these drugs become more widely available, it may well be a case of making the most of what we have – and that could just involve overcoming patient fears, and side-effects. A needle-free way of administering T-20 (enfuvirtide, Fuzeon) seems to be preferable to patients.
Illness
Yes, effective anti-HIV treatment has dramatically cut the rate of illness and death caused by HIV, but people with HIV are still more likely than the general HIV-negative population to experience ill health and die early, and a number of studies presented at Toronto looked at the spectrum of illness experienced by HIV-positive people today.
HIV is often not the only infection that many HIV-positive people have, and evidence from France showed how anal cancer, caused by infection with human papilloma virus (HPV), has increased amongst HIV-positive people in recent years. Similarly, as access to anti-HIV treatment in Africa improves, many women there may now be living long enough for cervical cancer to become an issue, and are therefore in need of screening and treatment programmes.
Hepatitis C virus can be bad news for people with HIV, but there was an encouraging study presented to the conference, suggesting that if anti-hepatitis C therapy is successful, an HIV-positive person is no more likely than a person who only has hepatitis C to develop long-term, serious liver problems.
An alternative approach
Lots of HIV-positive people use complementary or alternative therapies. The pluses and minuses of this were demonstrated by studies presented to the conference. Although one study found that selenium supplementation improved response to HIV therapy in patientsin Nigeria, a study from London showed that 10% of people on HIV treatment were taking complementary treatments that could either cause severe side-effects or dangerously interact with anti-HIV drugs. Tell your doctor or HIV pharmacist about every drug you are taking.
Prevention
As always, there was a lot of research presented on ways of preventing HIV. Circumcision, pre-exposure and post –exposure prophylaxis attracted the attention of Bill Gates and Bill Clinton and the world media.
But other interesting studies showed how treating sexually transmitted infections, particularly herpes simplex virus, can reduce genital shedding of HIV and the risk of on-ward transmission.
Other research showed the potential, and limitations, or “serosorting” (the selection of sexual partners of the same HIV status), as a means of reducing personal and community-wide HIV risk.
The studies suggested to me that contrary to what some people would like us to believe, HIV prevention is not as simple as ABC.
Healthy living
One eye-catching study showed that HIV-positive people in California had a significantly increased risk of the “super-bug” MRSA. Recent infection with syphilis seemed to be a factor in the infections, indicating a possible role for sexual risk-taking.
The recreational drug methamphetamine has demonic status in the HIV world, particularly in the US, and unsurprisingly, it was the subject of a lot of research presented at Toronto. Many of the studies were small, but they did show that use of the drug could interfere with adherence and accessing HIV care and that many HIV-positive people were using the drug to “self medicate” for chronic mental health problems.