The annual Conference on Retroviruses and Opportunistic Infections, taking place this week in Boston, was short on breaking news about HIV treatment and prevention, instead focusing on how to ensure access to existing effective therapies for everyone who needs them.
The more than 4,000 conference attendees heard about the ongoing scale-up of HIV treatment in low-income countries, as well as efforts to reach heavily affected populations such as gay men of color, people who inject drugs, and transgender women worldwide.
"Even in a single country, we're really looking at micro-epidemics," said CROI vice chair Dr. Sharon Hiller from the University of Pittsburgh. "Even in wealthy countries with - at least on paper - the best financed health systems, many people are still not being served well because they don't have access to care, lack insurance, or face other structural barriers that contribute to the continuation of the epidemic."
On the last day of the meeting more than 200 HIV researchers and clinicians released an open letter to President Donald Trump denouncing the "deterioration of evidence-based policymaking" under his administration, funding cuts for the National Institute for Allergy and Infectious Diseases and global AIDS programs, and a proposed "conscience" rule that would allow health care providers to discriminate against patients - including LGBT people and those living with HIV - based on their religious beliefs.
"President Trump's misguided budget proposal, and his administration's attempts to scale up policies in defiance of evidence, will only undermine the global AIDS response and should be stopped," wrote the signatories, including Dr. Diane Havlir, chief of HIV/AIDS at Zuckerberg San Francisco General Hospital.
Several studies presented at the meeting looked at new prevention and treatment options, including broadly neutralizing antibodies, vaginal rings for HIV prevention, and MK-8591, a long-acting nucleoside analog being tested for both treatment and PrEP.
During the conference the Food and Drug Administration approved ibalizumab (to be marketed as Trogarzo) for salvage treatment of people with highly resistant HIV. The first approved biological therapy for HIV, the monoclonal antibody will be priced at around $118,000 annually, far exceeding the cost of existing HIV therapies, according to members of the Fair Pricing Coalition.
Evolution of the epidemic
This was the 25th anniversary of CROI, and experts reflected on the evolution of HIV care and treatment since the early 1990s.
"The early days of HIV were a difficult time, but you start by doing what's necessary, then you do what's possible, and one day you find yourself doing the impossible," conference chair Dr. Judith Currier from UCLA said at the opening session.
Dr. Carlos del Rio of Emory University gave an overview of the evolving U.S. epidemic, noting that half of black gay and bisexual men will become infected with HIV if existing trends continue.
Del Rio said there is "no simple answer" to explain disparities in the epidemic in the South, but poverty, lower education level, structural racism, lack of health insurance, and failure to expand Medicaid all play a role. He suggested that the scale-up of PrEP could actually increase the racial disparity because African-American men are using it less. [See related story.]
Several speakers acknowledged San Francisco as having among the best records of success in addressing the epidemic.
Dr. Susan Buchbinder, director of Bridge HIV at the San Francisco Department of Public Health, described the city's Getting to Zero initiative, which includes widespread PrEP adoption and the RAPID program to start people on antiretroviral therapy on the same day they are diagnosed. These efforts have contributed to a 51 percent reduction in new infections from 2012 to 2016, she said.
But even here, racial and ethnic disparities remain.
"We have brought down HIV diagnoses in blacks, Hispanics, and whites, but we still have disparities. We need to make sure we get PrEP use to higher levels among those most at risk, or we will not reduce these disparities," Buchbinder said.
Acknowledging the diminishing African-American population in San Francisco, Buchbinder noted that city public health officials and community organizations are working with their colleagues in the East Bay and South Bay to improve outcomes throughout the region.
"People live, work, and play in multiple areas, and it's important we address HIV prevention and care throughout broader geographic area," she said.