Last week’s International AIDS Conference in Mexico City will be remembered for several things apart from traffic jams and tequila.
One was the emergence of a growing consensus that it is valid to talk about the prevention effects of treatment – and to promote earlier diagnosis and treatment as goals that will have prevention benefits at the population level.
There was less consensus regarding the effects of treatment on onward transmission for individuals. The conference heard conflicting data on the potential risk of HIV transmission by individuals who have undetectable viral load – including a warning that data from well-designed studies from which to issue guidance are still very limited.
The Mexico City conference will also be remembered for the high profile of another emerging issue – the criminalisation of HIV transmission. The conference heard strong condemnations of moves towards criminalising HIV transmission, but there are conflicting opinions about its uselfulness even among people with HIV.
Another important feature of the conference was its focus on the group most affected by HIV in Latin America – men who have sex with men – and the presentation of data from sub-Saharan Africa that must puncture the delusion that men who have sex with men are not a high-risk group in that region too.
There weren’t any memorable treatment breakthroughs at this year’s conference, but a great deal of new thinking about HIV prevention, in particular the need for `combination` prevention activities that combine biomedical, behavioural and structural interventions.
Future editions of HATIP will be exploring in more detail several topics that ran through this conference, including:
- Task-shifting: how to expand the health care workforce while delivering quality care.
- Drug resistance: what are the consequences of first-line failure when treatment failure cannot be detected early?
- Treatment for children: how is treatment for children being scaled-up in practice?
- HIV and TB in injecting drug users: what practical interventions can reduce the burden of TB in this group of people affected by HIV?
Antiretroviral therapy
How does abacavir/3TC compare to tenofovir/FTC? ACTG5202 and GSK studies disagree
Contradictory findings regarding the safety and efficacy of the dual-nucleoside combination of abacavir and 3TC were presented in a late-breaker session at the XVII International AIDS Conference on Thursday. A secondary analysis of 48-week data from the ACTG5202 study reasserted that the dual-nucleoside backbone of abacavir plus 3TC was more likely to lead to toxicity and earlier virologic failure than tenofovir plus FTC. However, a presentation from GlaxoSmithKline (GSK) indicated that, when data from other well-designed clinical trials was analysed using the same study endpoints as ACTG5202, abacavir/3TC proved just as tolerable and effective as tenofovir/FTC.
SMART study and 54-trial pooled analysis produce conflicting data about abacavir heart attack link
Data from the SMART trial provide further evidence that abacavir (Ziagen) may be associated with a higher rate of cardiovascular events, but a pooled analysis of more than 50 clinical trials conducted by abacavir’s manufacturer GlaxoSmithKline did not find any increased risk, attendees heard on Thursday at the XVII International AIDS Conference in Mexico City.
Two new NNRTIs look promising in early clinical trials
Two new non-nucleoside reverse transcriptase inhibitors (NNRTIs) have demonstrated good antiviral efficacy and favourable safety profiles in seven-day monotherapy trials, according to late-breaker presentations on Thursday at the XVII International AIDS Conference in Mexico City.
Men more likely to drop out of clinic care than women in western Kenya
Men are at much higher risk of becoming lost from HIV care programmes according to an analysis of clients attending USAID-AMPATH partnership’s HIV clinics in Western Kenya. This study, which also identified reasons why both men and women may be at risk of loss to follow-up (LTFU), was presented on Tuesday at the XVII International AIDS Conference in Mexico City.
Tenofovir kidney toxicity most likely with high blood pressure medications and PIs
Kidney toxicity is most likely to occur in patients taking tenofovir if they are controlling high blood pressure with potentially kidney-toxic drugs, and also taking protease inhibitors, delegates at the XVII International AIDS Conference heard on Wednesday.
Two novel immune therapies in early investigation: autologous dendritic cells and CD4 zeta gene-modified T cells
Immune cells extracted from individuals and then modified to enhance the individual immune response to HIV infection, appear to be a safe and feasible approach to HIV treatment, according to several reports this week at the XVII International AIDS Conference.
Urine biomarkers may predict cardiovascular disease in people taking antiretroviral therapy
Certain urine biomarkers related to inflammation and oxidant stress correlate with established predictors of cardiovascular disease and may help assess risk for heart problems among HIV-positive people on antiretroviral therapy according to a small pilot study presented on Wednesday at the XVII International AIDS Conference in Mexico City.
AIDS in 2031: where will we be?
AIDS experts looking towards the state of the epidemic in 2031 warned the XVII International AIDS Conference today that massive investment is needed to scale up the manufacture of antiretroviral drugs for up to 110 million people, and that international donors need to think in terms of `pension fund` type provision to plan for the scale of antiretroviral provision that will be needed by 2031.
Slowing CD4 cell decline with IL-2 allows HAART to be deferred by 92 weeks
Findings from ANRS 119, the Interstart trial, show that it may be possible to defer HAART treatment for nearly two years by using a limited number of short courses of interleukin-2 to keep CD4 cell counts above the recommended threshold for HAART initiation, Jean-Michel Molina of the University of Paris reported at the XVII International AIDS Conference in Mexico City on Tuesday.
Widespread NRTI and NNRTI resistance seen in Malawian patients failing first-line antiretroviral therapy
To date, few data have been reported on emerging drug resistance patterns in Africa. In an oral presentation at the International AIDS Conference in Mexico City on August 5th, delegates heard that drug resistance was widespread among people failing antiretroviral treatment in Malawi, due to lack of viral load testing to identify virologic treatment failure.
Infants starting ART less likely to completely suppress viral load
While antiretroviral therapy (ART) is a lifesaving intervention recommended for all HIV-positive infants in resources limited settings, younger children who begin ART do not appear to be as likely to suppress viral load as children who begin ART at a later age, according to findings of a South African study presented at AIDS 2008 in Mexico City on August 4th.
Efavirenz superior to lopinavir/ritonavir in very advanced HIV, Mexican trial shows
Efavirenz treatment results in a significantly higher rate of viral suppression after 48 weeks when compared to lopinavir/ritonavir, investigators of a randomised study among Mexican patients with very advanced HIV disease reported on Tuesday at the XVII International Conference on AIDS in Mexico City.
Treatment outcomes in Latin America, China and Botswana: successes and shortfalls
Dramatic benefits have come from antiretroviral therapy rollout programmes in resource-limited settings and around three million people are now receiving antiretroviral therapy in low- and middle-income countries. However, such programmes are vulnerable and depend on many factors for their continued success. Significant disparities are being seen in results between and within different geographical areas and populations, the XVII International AIDS Conference heard on Monday.
Raltegravir versus efavirenz in treatment-naives at 96 weeks: continued efficacy and fewer adverse effects
The integrase inhibitor raltegravir continues to show strong efficacy "almost identical" to that of efavirenz at 96 weeks, in combination with tenofovir and 3TC, and a side-effect profile that continues to be favourable, Dr Marty Markowitz of the Aaron Diamond AIDS Research Center reported on Tuesday at the XVII International AIDS Conference in Mexico City.
Switch to atazanavir does not reduce belly fat
Switching from other protease inhibitors to atazanavir/ritonavir does not significantly reduce visceral fat accumulation in the abdomen – a feature of the lipodystrophy syndrome - according to 48-week results of a randomised trial presented on Monday at the XVII International AIDS Conference in Mexico City.
Lipodystrophy common, but does not affect adherence in Thai patients
Lipodystrophy is common among Thai patients taking first-line therapy but has not affected adherence to treatment, a Thai research group reported on Monday at the XVII International AIDS Conference in Mexico City. However, the condition is not being managed by reducing the d4T dose as recommended by the World Health Organization in 2007.
Policy
Criminal HIV transmission and exposure laws spreading around the world ‘like a virus’
Concern over the growing international trend towards the criminalisation of HIV transmission or exposure was documented in a Wednesday morning session at the XVII International AIDS Conference that highlighted “criminalisation creep” in Europe and Central Asia as well as the rapid spread of “highly inefficient laws” in West and Central Africa.
TB/HIV
HIV programme in Western Kenya successfully delivers isoniazid preventive therapy to thousands
Isoniazid preventive therapy (IPT) can be successfully delivered by HIV treatment programmes to thousands of people according to a report from the USAID-AMPATH care programme in Western Kenya presented Monday at AIDS 2008 in Mexico City. Between September 2004, and February 2007, the programme put close to 10,000 people with HIV on IPT, achieving high rates of treatment completion with lower rates of TB in people who completed treatment.
New TB/HIV guidelines released to improve care and treatment of drug users
Global experts called on health and justice officials throughout the world to provide TB and HIV care and treatment for drug users during a press conference at the AIDS 2008 Conference in Mexico City this week.
Earlier ART benefits HIV/TB co-infected patients in Iran; Argentinian study yields uncertain results
Iranian and Argentinean researchers presented contradictory evidence on the risks of delaying antiretroviral therapy in people receiving TB treatment at the XVII International AIDS Conference in Mexico City, during a poster discussion on TB and HIV.
Prevention
Monkey study strengthens the case for a microbicide combining several anti-HIV drugs
A study using a microbicide gel containing the antiretroviral drugs in the combination pill Truvada – tenofovir and FTC (emtricitabine) – completely protected six pigtail macaque monkeys from infection with a type of HIV designed to be infectious to monkeys, the XVII International AIDS Conference heard on Thursday.
Protective effect of circumcision is sustained for at least 3.5 years; also works against HPV
The protective effect of circumcision against HIV infection remains unchanged for at least 42 months after the operation, the lead investigator from the randomised controlled trial (RCT) in Kisumu, Kenya, told the XVII International AIDS Conference on Thursday in Mexico City.
Systematic review unable to confirm or disprove Swiss statement on infection risk with undetectable viral load
A systematic review of studies of serodiscordant couples where the HIV-positive partner was on antiretroviral treatment could neither confirm not disprove the recent Swiss declaration of a negligible risk of HIV transmission from a pesron on treatment with undetectable viral load, according to data presented during Thursday afternoon’s late breaker sessions at the XVII International AIDS Conference in Mexico City.
Swiss statement that ‘undetectable equals uninfectious’ creates more controversy in Mexico City
Science took a back seat to politics during one of the most controversial sessions of the XVII International AIDS Conference in Mexico City – one that took place hours before the conference had officially opened. At a specially convened satellite event, seven influential panellists discussed the implications of the Swiss Federal AIDS Commission’s controversial January statement – that an undetectable viral load in the blood renders an individual uninfectious, under optimal conditions.
Skills-building behavioural interventions advocated for reducing alcohol-related HIV risk in South Africa
Findings from a South African study presented on Wednesday at the XVII International AIDS Conference suggest that people whose alcohol consumption puts them at higher risk of HIV infection may benefit from skills-building risk reduction interventions.
Treatment as prevention tool: enough evidence to say it works, says IAS president
While experts are at loggerheads over the recent statement that HIV-positive heterosexual individuals who have undetectable viral load and no other sexually transmitted infections, should not be considered at risk of transmitting HIV to others, there was a striking degree of unanimity among a range of experts at the XVII International AIDS Conference that expanding the number of people on antiretroviral treatment will reduce the number of new infections at a population level.
Major prevention success for sex workers and men who have sex with men in India
A comprehensive HIV prevention programme targeted to men who have sex with men and female sex workers in India has had a major impact on reported condom use and incidence of sexually transmitted infections, according to the evaluation results presented by Alvaro Bernejo of the International HIV/AIDS Alliance at the International AIDS Conference in Mexico City on August 6th.
Circumcision will halve HIV rates but may take decades to reach full impact
Tripling the rate of male circumcision in a country with a current circumcision rate of 25% and a high rate of heterosexually-acquired HIV will eventually halve HIV incidence, a mathematical model by Richard White of the London School of Hygiene and Tropical Medicine has shown.
Prevention – there will be no magic bullet, we need ‘combination prevention’
Whether described as “combination prevention” or “highly active HIV prevention”, the emphasis at the International AIDS Conference in Mexico City has been on the need for multi-pronged prevention programmes. This was especially the case at a special session convened by The Lancet on August 5th, where some of the world’s leading researchers called for HIV prevention efforts to be redoubled, in a manner equivalent to the campaign to provide universal access to HIV treatment.
Microfinance project reduces HIV risk in South African women, gold standard trial shows
A microfinance and training project designed to empower South African women was associated with a significant reduction in HIV risk behaviour and partner violence over two years of follow-up, delegates heard at the XVII International AIDS Conference in Mexico City on Monday.
US HIV incidence 40% higher than previous estimates, new test shows
Based on a new testing technique that can distinguish recent from long-standing HIV infections, the U.S. Centers for Disease Control and Prevention (CDC) now estimates that there were 56,300 new HIV infections in the U.S. in 2006—about 40% higher than the previous estimate. The figures were released on August 2, in advance of the XVII International AIDS Conference in Mexico City, and published in the August 6 edition of the Journal of the American Medical Association.
HIV-1 subtype, genital ulcer disease influence risk of HIV transmission among heterosexual couples
Viral subtype may influence the likelihood of HIV transmission between heterosexual couples, and concurrent genital ulcer disease (GUD) plays a clear role, according to a study from Uganda presented yesterday at the XVII International AIDS Conference in Mexico City.
South African men with genital ulcers have very high incidence of HIV and should be a target of prevention interventions
Almost two thirds of South African men presenting with genital ulcer disease are already HIV-positive, and a further 12% of the HIV-negative men acquire HIV within the next month, according to a study presented at the International AIDS Conference in Mexico City on August 5th. The researchers concluded that men with genital ulcer disease should be targeted for HIV testing and prevention interventions.
Who defines ‘Positive prevention’?
Structured, theory-based prevention programmes for people with HIV can be very effective, the XVII World AIDS Conference heard on Monday, with one programme reporting a 67% decline in risk in gay men given peer training. But it also heard that there is disagreement among HIV-positive activists as to whether people with HIV should be targets for interventions to reduce HIV transmission at all.
Men who have sex with men
Invisible men: action urged for gay men in the global South
“This epidemic never ceases to surprise us. In every major city in Asia we have looked at, there are now epidemics of HIV among men who have sex with men (MSM) – epidemics that remind me of what we saw in the USA and Europe in the 1980s. HIV is now rising as fast in those men as it was then. This was the warning given by Peter Piot, retiring Director of UNAIDS, at the satellite meeting on gay men/MSM preceding the 2008 World AIDS Conference in Mexico City.
Malawi MSM survey reveals very high HIV acquisition and transmission risks
The first figures released from a series of systematic surveys of men who have sex with men in southern Africa has revealed, at least in the first site analysed in Malawi, very high levels of behaviours likely to enhance the spread of HIV. The figures were presented at the meeting of the Global Forum on Men who have Sex with Men and HIV, a satellite conference on gay men and MSM attended by nearly 500 people in the two days preceding the World AIDS Conference.
High HIV incidence among young Thai men who have sex with men
The first ever study of the incidence of new HIV infections among men who have sex with men in Thailand has shown that each year 5% acquire HIV, reported Wipas Wimonsate from the Thai Ministry of Public Health at the International AIDS Conference in Mexico City on August 4th. The men recruited to this study will continue to be followed for three years, and the data from the study will help the planning of HIV prevention in this group.
Which gay men should be the target for prevention work?
Researchers at the International AIDS Conference in Mexico City have suggested a range of approaches for better defining the characteristics of gay men who are at greatest risk of being involved in HIV exposure or transmission, and who can be targeted for HIV prevention interventions.
World AIDS conference comes to Latin America
The first International AIDS Conference to focus on Latin America will open tomorrow in Mexico City, the largest city in the Spanish-speaking world. The conference, held every two years, is the biggest gathering of AIDS experts, advocates, people with HIV and physicians, and this year it has attracted more than 22,000 delegates.