New research was presented at IAS 2015, the International AIDS Society Conference, from July 19 to 22 in Vancouver, Canada. The features below highlight some of the studies that emerged from the conference.
Benefits Seen With Widespread ART Access
The Particulars: Widespread HIV screening and access to highly active antiretroviral therapy (ART) have been shown to be cost effective in mathematical models. However, the costs, value, and feasibility of complete access to ART have yet to be determined.
Data Breakdown: For a study, Canadian researchers assessed the cost-effectiveness of universal ART access in British Columbia from 1997 to 2010 and compared it with hypothetical scenarios of constrained treatment access. The study team estimated savings of 65.5 million Canadian dollars by 2035, based on the difference between a 100% probability of accessing ART and a 50% probability. Savings based on a 75% probability would be $25.1 million by 2035.
Take Home Pearl: Universal access to ART appears to result in substantial cost savings over the long term.
ART Halts HIV Transmission in Heterosexual Couples
The Particulars: Data are lacking on the ability of antiretroviral therapy (ART) to stop HIV transmission from an infected person to their partner among heterosexual discordant couples.
Data Breakdown: For a study, infected patients were randomized to immediate ART treatment or to wait until their CD4 count fell below 250 cells/mm3. Transmission of HIV was reduced by 93% among couples in which the infected partner received ART. Transmission only occurred when HIV was not fully suppressed or when treatment had failed.
Take Home Pearl: Effective ART appears to prevent the vast majority of HIV transmission among heterosexual discordant couples.
Opioid Agonist Therapy in HIV-Positive Drug Users
The Particulars: Studies have shown that drug use is an important contributor to the HIV epidemic. However, some studies indicate that injection drug users are less likely than others with HIV to receive treatment for their infection or their drug use. Access to opioid agonist therapy may lead to better outcomes in this patient population.
Data Breakdown: Study investigators analyzed data on injection drug users living with HIV between 1996 and 2010. Those who received opioid agonist therapy had a mortality rate of 12.2%, compared with a rate of 30.0% that was observed among those who did not receive these medications. Together with antiretroviral therapy, opioid agonist therapy reduced all-cause mortality by 84%.
Take Home Pearl: Opioid agonist therapy appears to substantially decrease HIV- and drug-related mortality in injection drug users with HIV.
ART for Early Asymptomatic HIV
The Particulars: Few studies have assessed the benefits and risks of initiating antiretroviral therapy (ART) in patients with asymptomatic HIV and CD4 counts of 350 cells/mm3 or higher.
Data Breakdown: For a study, HIV-positive adults with CD4 counts of more than 500 cells/ mm3 were randomized to start ART immediately or to defer it until their counts decreased to 350 cells/mm3 or the development of AIDS. A composite of any serious AIDS-related event, serious non-AIDS-related event, or mortality occurred in 1.8% of the immediate treatment group, compared with a 4.1% rate that was observed in the deferred-initiation group.
Take Home Pearl: Initiating ART in HIV-positive adults with CD4 counts higher than 500 cells/ mm3 appears to improve outcomes over deferring treatment until after CD4 counts decline to 350 cells/mm3.
PrEP Adherence Support Needed for YMSM
The Particulars: Young men who have sex with men (YMSM)—particularly racial and ethnic minorities—have been shown to be at increased risk for HIV in previous research. However, data are lacking on the uptake and adherence to pre-exposure prophylaxis (PrEP) in this population.
Data Breakdown: A diverse group of YMSM were studied in 12 cities in the United States to examine PrEP uptake and adherence. The majority of participants (56%) achieved protective drug levels by week 4 of the study. However, adherence to PrEP declined to 34% as visits decreased from a monthly basis through week 12 to a quarterly basis through week 48.
Take Home Pearls: Among YMSM, access to PrEP in youth-friendly settings may help optimize the effects of this treatment. Adherence support may need to be tailored and visit schedules may require augmentation for this patient population.
HIV Testing Increases in Male Partners of Women Given Self-Test Kits
The Particulars: HIV self-testing has been hypothesized to be an appealing option for men because it offers a private, easy alternative to standard testing. Distributing self-tests to men has remained a challenge, however. Researchers believed that pregnant and postpartum women seeking healthcare as well as female sex workers receiving HIV prevention services would be good candidates for distributing HIV self-tests to male partners.
Data Breakdown: For a study, 280 HIV-uninfected pregnant or postpartum women and female sex workers were taught how to use an HIV self-test and encouraged to distribute to their male partners or clients at their discretion. Based on interviews at 1, 2, and 3 months, only about 15% of distributed tests were not used. Of tests distributed, nearly 98% were used by the person it was given to. Overall, 4.8% of pregnant women’s and 3.3% of postpartum women’s partners tested positive for HIV, as did 15.3% of sex worker’s clients.
Take Home Pearl: High proportions of men appear to be likely to complete HIV self-tests when the tests are provided to them by pregnant or postpartum women or female sex workers.
Asymptomatic Neurocognitive Impairment & HIV
The Particulars: Prior research indicates that HIV-associated neurocognitive disorders are common among patients with HIV. Whether these disorders are related to HIV or are simply more common in people with lifestyles that are associated with HIV risk has yet to be determined. Also, little is known about whether asymptomatic neurocognitive impairment is predictive of progression to more serious and symptomatic neurocognitive impairment.
Data Breakdown: Adults receiving HIV care underwent neuropsychological testing annually for a study to assess cognitive symptoms. Among those with asymptomatic neurocognitive impairment at baseline, 27% progressed to symptomatic HIV-associated neurocognitive disorder, compared with a rate of 15% observed among those with normal neurocognitive function at baseline.
Take Home Pearl: Asymptomatic neurocognitive impairment in patients with HIV appears to increase the risk of progression to symptomatic HIV-associated neurocognitive disorder.
Viral Suppression in HIV-Positive Youth
The Particulars: Previous studies indicate that about 25% of all new HIV infections in the United States occur in patients aged 13 to 24. However, data on engagement in care for youths with HIV are lacking.
Data Breakdown: Researchers assessed outcomes in patients aged 12 to 24 who were diagnosed with HIV for a study. Among participants, 54% were linked to care, 31% were retained in care, 31% started antiretroviral therapy, and only 7% achieved an undetectable viral load. The viral suppression rate of 7% compares with an approximately 40% for all age groups according to statistics from the CDC.
Take Home Pearl: Youth with HIV appear to achieve viral suppression at a rate substantially lower than that achieved by the combination of all age groups of patients with HIV.
Steatosis in HIV/HCV Coinfection
The Particulars: Patients with HIV/hepatitis C virus (HCV) coinfection have been shown in previous studies to typically experience more aggressive liver disease progression than those with either infection alone. Coinfected patients are also more likely to develop liver steatosis and fibrosis. However, few studies have assessed the impact of steatosis on fibrosis progression, cardiovascular disease, and survival in patients with HIV/HCV coinfection.
Data Breakdown: For a study, 10-year clinical outcomes were analyzed for patients with HIV/HCV coinfection who received liver biopsies for HCV-related liver disease. Evidence of steatosis was observed in 56% of patients. Those with steatosis were more likely to be men, overweight or obese, and to drink alcohol. Steatosis increased the risk for diabetes, diabetes, decompensated liver disease, coronary artery disease, peripheral vascular disease, and myocardial infarction, when compared with those without steatosis, but these differences were not significant. Survival rates for patients with and without steatosis were 88% and 93%, respectively, at 5 years and 65% and 73%, respectively, at 10 years.
Take Home Pearls: Patients with HIV/HCV coinfection appear to have a 10-year mortality rate of about 25%. Coinfected patients with steatosis appear to have increased risks for cardiovascular events and diabetes and decreased survival when compared with those without steatosis.
ART Unaffected by Contraception
The Particulars: The limited number of studies assessing the impact of contraceptive methods on the efficacy of antiretroviral therapy have provided unclear findings.
Data Breakdown: Over 8 years, study investigators assessed the incident pregnancy rates of women with HIV who used implant, injectable, or oral contraception. When compared with no contraception use, implants reduced the risk of pregnancy by more than 90%, among women both on and not on ART; injectable and oral contraceptives reduced this risk by 82% and 60%, respectively.
Take Home Pearl: Horomonal contraceptives, particularly implants and injectables, appear to be effective for women with HIV who are on ART.
Readings & Resources (click to view)
For more information on these studies and others that were presented at IAS 2015, visit www.ias2015.org.