{"id":279,"date":"2009-02-13T17:49:48","date_gmt":"2009-02-13T22:49:48","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=279"},"modified":"2015-06-04T15:31:17","modified_gmt":"2015-06-04T19:31:17","slug":"croi-2009-greatest-hits","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/croi-2009-greatest-hits\/2009\/02\/13\/","title":{"rendered":"CROI 2009: Greatest Hits"},"content":{"rendered":"

\"\"<\/a>Fresh back from lovely Montreal, where the temperature (I’m glad to report) climbed into the balmy 40’s …<\/p>\n

Here’s a rapid-fire listing of the Greatest Hits.\u00a0 As I’m sure to be leaving something off this list, happy to accept other suggestions:<\/p>\n

    \n
  1. Interleukin-2 does not work<\/strong>.\u00a0 The ESPRIT<\/a> and SILCAAT<\/a> studies are over. Yes, the CD4’s increase, but compared to antiretroviral therapy alone, there’s absolutely no clinical benefit, and plenty of side effects.<\/li>\n
  2. Should we be starting antiretroviral therapy at even higher CD4s?<\/strong> At ICAAC, the NA-ACCORD group said starting before 350 improved survival; here<\/a> they said it was 500!\u00a0 The ART-CC<\/a> disagreed, slightly (their estimate was around 350).<\/li>\n
  3. Switching from lopinavir\/r to raltegravir increases the risk of virologic failure<\/a> in suppressed patients. <\/strong> Likely explanation:\u00a0 undetected NRTI resistance at baseline.\u00a0 This study should have no bearing on the use of raltegravir in either treatment-naive or treatment-experienced patients — essentially, the drug must be used with at least one other fully active agent.\u00a0 (Oh yeah, the lipids improved, not surprisingly.)<\/li>\n
  4. Treating HIV during TB treatment increases survival compared with waiting until TB therapy is completed.<\/strong><\/a> One of the most interesting things about this study is that TB treatment outcomes were similar — but those who delayed therapy obviously had HIV disease progression.\u00a0 By contrast, a small study of cryptococcal meningitis<\/a> from Zambia suggested that early ART was harmful — the first time early ART has been associated with worse outcomes.<\/li>\n
  5. Treating HIV significantly reduces the risk of HIV transmission to a seronegative partner.<\/strong><\/a> This study from Zambia and Uganda involved nearly 3000 discordant couples (!), and the effect was dramatic — especially when one considers that HIV therapy was only given if clinically indicated (i.e., not to prevent transmission).<\/li>\n
  6. …But the risk of transmission is not zero.<\/strong> Some <\/a>studies<\/a> showed persistent HIV shedding in semen despite effective antiretroviral therapy.\u00a0 No surprise — but this doesn’t diminish my enthusiasm for #5 above, as the reduction in risk from treatment is huge.<\/li>\n
  7. Antivirals and cardiovascular disease. <\/strong> D:A:D is updated<\/a>, and continues to implicate abacavir, and a French Hospital Database study<\/a> does the same — and both now cite lopinavir\/r as associated with increased risk as well.\u00a0 An ACTG database study<\/a> does not find an association with abacavir, but a prospective randomized switch trial (to ABC\/3TC or TDF\/FTC) does<\/a> — in the updated analysis, the difference was statistically significant.\u00a0 Regarding abacavir, pathogenesis studies were all over the place — split about evenly whether positive or negative.\u00a0 Peter Reiss gave a sensational summary<\/a> on this complex issue — web cast highly recommended if you have 15 minutes to spare.<\/li>\n
  8. Lopinavir\/r is better than nevirapine<\/a> for women who previously received single-dose nevirapine.<\/strong> This might seem intuitively obvious, but it answers an important question that has generated enormous controversy over the years.\u00a0 (Plus the first author is a beloved colleague.)<\/li>\n
  9. Two non-ritonavir boosters are introduced.<\/strong> (Details here<\/a> and here<\/a>.)\u00a0 Yes, data are early, but something without the GI and lipid effects would be welcome indeed.\u00a0 Whether we really will need PK boosters at all remains an open question, but for now they clearly are needed for PIs and the investigational integrase inhibitor elvitegravir.<\/li>\n
  10. A microbicide works<\/strong><\/a>.\u00a0 Sort of.<\/li>\n<\/ol>\n

    So what’s missing?\u00a0 Not a single phase III study of a novel agent, nor a phase IV comparative trial of existing drugs done in the developed world.<\/p>\n

    Yes, it’s a very “quiet” phase in HIV drug development — too quiet.\u00a0 If this poster<\/a> is a harbinger of what’s coming with integrase resistance, let’s hope it’s not quiet for long.<\/p>\n","protected":false},"excerpt":{"rendered":"

    Fresh back from lovely Montreal, where the temperature (I’m glad to report) climbed into the balmy 40’s … Here’s a rapid-fire listing of the Greatest Hits.\u00a0 As I’m sure to be leaving something off this list, happy to accept other suggestions: Interleukin-2 does not work.\u00a0 The ESPRIT and SILCAAT studies are over. Yes, the CD4’s […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2,4,5,6],"tags":[13,20,36,77,83,162,190,244,266,278,290,300,423,429,450,451,515,567,779,801,817,899,900],"class_list":["post-279","post","type-post","status-publish","format-standard","hentry","category-antiretroviral-rounds","category-hiv","category-infectious-diseases","category-medical-education","tag-13","tag-abacavir","tag-active-agent","tag-antiretroviral-therapy","tag-art","tag-cd4","tag-clinical-benefit","tag-croi","tag-darunavir","tag-discordant-couples","tag-drug-development","tag-early-art","tag-hiv","tag-hiv-disease-progression","tag-hiv-therapy","tag-hiv-transmission","tag-interleukin-2","tag-lipids","tag-raltegravir","tag-resistance","tag-ritonavir","tag-tb-therapy","tag-tb-treatment"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/279","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=279"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/279\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=279"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=279"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=279"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}