HIV and ID Observations

Last week’s International AIDS Conference in Washington got plenty of media attention, mostly because it was the first time in umpteen years that it was held in the United States, the delay between meetings due to our absurd (and now repealed) immigration laws regarding HIV.

(Quick trivia question — where was the conference supposed to be in 1991 when it was cancelled?)

As is typical of these meetings, which alternate with the smaller International AIDS Society Conference from year-to-year, there was plenty going on from a political and activist perspective. Still, there was some notable clinical research, so here then is a Really Rapid Review© of some conference highlights, both scientific and otherwise.

• More cases of cure following bone marrow transplantation? Could be — and these two guys didn’t even have donors with the CCR5 delta-32 mutation. Note that they remain on ART at this point, so all this is speculative, very preliminary. (Kudos to my colleague Tim Henrich for this innovative study, and of course to his/our boss, Dan Kuritzkes. Note that I’d lead off with this one even if he weren’t our boss …)
• Dolutegravir is non-inferior to raltegravir in treatment-naive patients. Not only that, but virologic failures had no resistance. Could dolutegravir be the first agent that isn’t a boosted PI with the same enviable high barrier to resistance?
• Speaking of boosted PIs, virologically suppressed patients who switched to co-formulated tenofovir/FTC/rilpivirine maintained suppression. Lipids also much better. Fewer pills. Fewer drug-drug interactions. Fewer GI side effects. This might be the ultimate use of this pill, when you think about it.
• Cobicistat non-inferior to ritonavir when used as a booster. It’s slightly disappointing that it’s not better in some way, but oh well. At least coformulations appear to be much more likely than with ritonavir.
• More underwhelming results from pilot studies of two-active-drug, NRTI-sparing strategies — maraviroc plus atazanavir/r and maraviroc plus darunavir/r. A fully powered study of the latter combination is ongoing.
• In 052 — early vs deferred ART to prevent transmission — the delayed treatment-arm had more AIDS events and also more HIV-related, non-AIDS events than the early-treatment arm. You know, treating HIV and keeping those CD4s up is a good thing. Cost effective, too.
• What’s the right dose of raltegravir to use with rifampin? The answer on the boards is “800 mg twice daily”, but in this study, 400 mg twice daily performed just as well and so did efavirenz. I’d still probably go with 800 mg twice daily. (That is, if we actually had much HIV-related TB in Boston — last year there were only 44 cases, and most of them of course in HIV-negative people.)
• New drugs for tuberculosis — including this linezolid-like compound, sutezolid— are actually on the way.
• Coformulated tenofovir/FTC/efavirenz is the most widely used initial regimen, but what will happen when generic efavirenz comes along? A modeling study showed that using tenofovir + generic FTC + generic efavirenz will offer substantial cost savings over the coformulation. The trade-offf? Less convenience, lower efficacy, more resistance — all of these varied in sensitivity analyses, which didn’t really reduce the cost savings but may make it hard to switch unless we have to. (Disclosure, I’m a co-author on this one.)
• More data suggesting accelerated aging in HIV. In this carefully done cohort analysis, non-infectious medical problems came to people with HIV 5 years earlier than in uninfected controls. These conditions were something they called “age-associated non-communicable comorbidity”, or AANCC. Catchy.
• Causes of death in HIV have changed substantially over the last 12 years. Large D:A:D study, with plenty of good news: Death rate fell from 17.4 deaths per 1000 py in 1999-2000 to 8.3 deaths in 2009-2011, with significant declines not only in AIDS mortality, but also in rates of both liver and cardiovascular death.
• You know that oft-cited “cascade” of care (figure at the bottom of the link), showing what a small proportion of people with HIV in the United States are actually on treatment with suppressed viral loads? The situation is even more alarming when broken down by demographics, with only 21% of African Americans and 15% of 15-34 year olds on suppressive treatment. Not surprising, but important nonetheless.

Now the non-scientific part.

• Hilary Clinton was great in one of the opening plenaries. As is inevitable for these conferences, vocal protesters interrupted her as she began speaking; she handled them perfectly, citing how important protests have been to advance the HIV cause. But come on — I can’t think of any major politicians who have done more for HIV than the Clintons — why protest her at all?
• Yes, it was hot — really hot, this was Washington in July, after all — but fortunately not as hot as it was the week before the conference, when even the locals were complaining. For the record, on the day I flew back, it was 97 in Washington, 77 in Boston.
• Heat notwithstanding, these bikes are a great way of seeing the city sites. Just … ride … very … slowly.
• The National Gallery is simply one of the best art museums on the planet — and it’s free! The George Bellows exhibit (representative painting above, click on it to enlarge) was sensational — and not just because he was recruited to play professional baseball while in college.
• There was the familiar prominent display of condoms, etc by these folks. I bet the cardiologists don’t get a similar opportunity during their big meetings. But I truly hope they (the condom people) leave the microphone at home next time, yikes that was loud.

Next year’s conference is in Kuala Lumpur — which is, amazingly, not quite as hot in the summertime as Washington, DC, but is much harder to get to, at least for those of us living in this hemisphere. It will be interesting to see what kind of attendance the conference gets.