Issue:  Vol. 48 / No. 8 / 22 February 2018

AIDS confab highlights
treatment and prevention


PrEP researcher Robert Grant signs the Vancouver Consensus at the International AIDS Society conference. Photo: Liz Highleyman
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The 2015 International AIDS Society conference will be remembered as a milestone in the global effort to eliminate new infections and expand treatment to everyone living with HIV worldwide, experts said this week in Vancouver.

Many recalled that Vancouver was also the site of the 1996 International AIDS Conference, where researchers presented the first study results that ushered in the era of effective combination antiretroviral treatment that saved countless lives.

"IAS 2015 will be remembered as the definitive moment when the world agreed that earlier initiation of treatment is the best way to preserve the health of people living with HIV and one of the best tools we have to slow HIV transmission to others," said conference Co-Chair Julio Montaner from the British Columbia Centre for Excellence in HIV/AIDS.

Speakers at the opening session on Sunday celebrated the achievements of recent years, while also acknowledging the challenges that remain.

UNAIDS recently announced that 15 million people are now on antiretroviral treatment worldwide and 83 countries have been able to stabilize or reduce the number of new HIV infections. An estimated 30 million new infections and 8 million deaths have been averted during the past 15 years.

"Fifteen years ago people were saying we were dreamers," said UNAIDS Executive Director Michel Sidibe. "They were completely wrong. The 10,000 people [then] on treatment has swelled to 15 million. We brought the price down from $10,000 to $100 [per person per year]. We used to give 18 pills a day, now it's one pill a day, and soon it will be one injection every six months."

The current UNAIDS target – known as 90-90-90 – aims to get 90 percent of people with HIV to know their status, 90 percent of these to be on treatment, and 90 percent of those to have undetectable viral load. Meeting these goals by 2020 could virtually eliminate the HIV/AIDS pandemic by 2030, mathematical models suggest.


Study supports treatment for all

Researchers presented data at the conference from a number of key studies showing that antiretroviral therapy both improves the health and extends the lives of people with HIV, as well as preventing transmission to HIV-negative people.

Jens Lundgren from the University of Copenhagen presented final results from the START (Strategic Timing of Antiretroviral Treatment) trial, which aimed to settle the controversy over the optimal time to initiate therapy.

START enrolled more than 4,600 HIV-positive people in 35 countries who were randomly assigned to either start treatment immediately regardless of CD4 T-cell count or to delay therapy until their CD4 count fell below 350 or they developed AIDS symptoms.

The study was halted in May after a data monitoring committee determined that there was already enough evidence to show an advantage for early treatment.

Lungren reported that 1.8 percent of participants in the immediate treatment group experienced serious AIDS-related events, non-AIDS events, or death, compared with 4.1 percent in the deferred therapy group – a 57 percent reduction.

Serious AIDS events decreased by 72 percent, with tuberculosis being the most common event in both treatment arms. Serious non-AIDS events fell by 39 percent, largely driven by half as many cancer cases in the early treatment group.

START provides the evidence some were waiting for to conclude that everyone living with HIV should be offered treatment.

In 2010, San Francisco became the first city to offer treatment to everyone diagnosed with HIV. U.S. treatment guidelines made the same recommendation in 2013. This week the World Health Organization announced that its forthcoming guidelines will likewise recommend treatment for all.

"[START] clearly indicates that antiretroviral therapy should be provided for everyone regardless of CD4 count," Lundgren told the Bay Area Reporter. "Now we have evidence that aligns individual benefit and prevention benefit without evidence of harm."

"Let this be the conference where the question of when to start treatment becomes not a question of science, but one of financing and political will," conference Co-Chair Chris Beyrer from Johns Hopkins University said at the opening session.


Focus on prevention

In line with other recent meetings, the Vancouver conference included little breaking news about new and improved HIV treatment, but several studies added to the understanding of biomedical prevention.

Myron Cohen from the University of North Carolina presented final results from the HIV Prevention Trials Network study 052, which looked at antiretroviral treatment as prevention for serodiscordant (mixed HIV status) heterosexual couples in Africa.

The trial previously made headlines when Cohen announced at the 2011 IAS conference in Rome that HIV-positive people who started treatment immediately instead of waiting for their CD4 count to fall had a 96 percent lower risk of transmitting HIV to their partners.

The study ended in May and Cohen reported final data showing that early treatment led to an overall 93 percent reduction in transmissions within couples, while also improving the health of the HIV-positive partners. When transmission did occur, it was usually soon after starting treatment before viral load became undetectable.

Also on the treatment front, pre-exposure prophylaxis, better known as PrEP, was among the hottest topics at the conference.

Researchers reported new findings from HPTN study 067 – conducted in Harlem, Bangkok, and Cape Town – showing that taking PrEP before and after sex may be an option for some people, though daily dosing led to better adherence.

Conference delegates also heard findings from several real-world PrEP programs, including PrEP Demo Projects in San Francisco, Miami, and Washington, D.C. (PrEP research will be covered in more detail next week.)


Who is left behind?

While the overall tone of the conference was optimistic, speakers also called attention to the barriers that stand in the way of bringing HIV testing, care, and treatment to heavily affected but underserved groups including gay men, transgender people, people who inject drugs, sex workers, and people living in areas where stingy funding and repressive laws hamper the response to the epidemic

"To achieve the 90-90-90 targets we need to look for game changers – it's not going to happen with business as usual," said UNAIDS deputy executive director Luiz Loures. "The epidemic is about those who are left behind. ... We need to empower people to be able to make decisions about their health and life."

Delegates at the 2015 IAS conference released a call to action to sustain and intensify the response to the epidemic. The Vancouver Consensus statement – endorsed by the conference organizers, major agencies including UNAIDS and PEPFAR, and leading researchers and advocates – is intended to pressure governments and donors to support expanded HIV treatment and prevention.

"Vancouver will be the place where we draw the line in the sand," Montaner said at Sunday's news conference. "Politicians have to decide whether they're with us or against us. We know the evidence and we know what needs to be done."

Dazon Dixon Diallo, with SisterLove in Atlanta and the U.S. Women and PrEP Working Group, emphasized the challenges of bringing early antiretroviral therapy, treatment as prevention, and PrEP to the people who need them most.

"We know that we have consensus about the science ... [but] we need to extend it to the real world," she said. While global HIV/AIDS leaders talk about the 90-90-90 goals, "there are still voices concerned about the 10-10-10 that still need to be reached."


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