The panel at the HIV cure press conference.  © IAS/Deborah W. Campos - Commercialimage.net

Some of the latest HIV cure research has been presented at International AIDS Conference this week.

Experts also met for a cure workshop prior to the conference, where they launched a global scientific strategy Towards an HIV Cure.

Research is looking at a range of different approaches to a possible cure, including:

• flushing out and destroying HIV lying dormant in ‘reservoirs’ in the body.
• stem cell treatment (like that which cured the ‘Berlin Patient’)
• starting HIV treatment very soon after infection – an approach that would only work for a small proportion of people with HIV.

It’s likely any successful cure process will involve a combination of approaches.

Promising results in some of the cure studies raise their own ethical questions, as people who are doing well on successful HIV treatment would have to stop to see if a functional cure has been achieved. An ethics working group has been set up to address these issues.

Steven Deeks, co-chair with Francois Barré-Sinoussi of the IAS HIV Cure working group, said: "The barriers to a cure are far greater than barriers to antiretroviral therapy [in the late 1980s]… Unless we get very lucky this is going to take well over a decade."

"The field is moving fast", said Sharon Lewin from Monash University in Melbourne. "We certainly don’t have a cure currently, but we have a better understanding of what we need to do."

Image: WHO/TBP/Gary Hampton

Twelve months of isoniazid (INH) preventive therapy (IPT) significantly reduced the incidence of all TB diagnoses in people with HIV who are also on antiretroviral therapy (ART), according to large randomised study conducted in Khayelitsha, South Africa.

“There was a 37% reduction in the rate of incident TB in the INH treatment group compared to those who were receiving ART alone,” said Dr Molebogeng Xheedhe Rangaka of the University of Cape Town, who presented the study findings.

This was a ‘late breaker’ at the conference and a full news story will be published on aidsmap tomorrow.

In other TB news, infection with HIV does not have an impact on the time taken to cure multidrug-resistant tuberculosis (MDR-TB), results of a study conducted in Botswana show.

TB is one of the most important causes of serious illness and death in people with HIV.

Strains of TB have emerged that are resistant to key drugs. Treatment for MDR-TB is more complicated than therapy for drug-sensitive TB and it also takes longer.

The results of the latest study show that therapy for MDR-TB has the same success rate in HIV-positive people as in people who are HIV negative.

In addition, the duration of treatment needed to achieve a cure did not differ by HIV status.

Images from the presentation of Dr Rachel Baggaley of the World Health Organisation.

Community-based support increases the likelihood that HIV-positive people will be retained in care, research conducted in South Africa shows.

Less than a third of people who start HIV therapy in southern Africa stay in HIV care. This is of serious concern. It means that the majority of people with HIV are not receiving the health benefits that come from specialist treatment and care. A high drop-out rate from care also seriously undermines the use of HIV treatment as prevention.

A speaker from the World Health Organization (WHO) presented findings from research in more than 20 countries about why people fall out of care at some point in the ‘cascade’ of HIV care (that is, the different stages of care from first being tested to being on effective treatment ). Reasons include the fear of stigma, denial about their condition, anxiety, poor links with the care available, inadequate clinic facilities and problems with travel.

But a South African study showed that providing community-based adherence support increased the chances that people starting HIV treatment would stay in care.

A new healthcare role of ‘patient advocates’ was introduced in 2004. These workers help support adherence and also provide counselling and psychosocial support.

Only 6% of people who had an advocate dropped out of care, compared to 10% of individuals who did not receive this kind of support.

Separate research showed that contact tracing could help reduce drop-out rates among children after starting HIV treatment.

Following the introduction of active contact tracing, rates of loss-to-follow-up were reduced from 22.7% to 8.5%.

The WHO report recommends the involvement of lay health workers to help ensure people move from one stage of the care ‘cascade’ to the next, and therefore stay in care.

In partnership with UNICEF

Rene Ekpini of UNICEF. © IAS/Steve Shapiro - Commercialimage.net

On the same theme of keeping people in care, the Washington conference was told that three-quarters of children in need of HIV therapy are not receiving treatment, an unacceptable situation.

However, a variety of schemes show that this situation can be remedied.

One, implemented in Malawi, includes the provision of lifelong HIV treatment to all HIV-positive pregnant women, regardless of their CD4 cell count.

Another intervention in Zimbabwe has increased rates of diagnoses among children.

A number of practical measures – often with the local community playing a pivotal role – were also improving the retention of children in care.

These included:

• Use of community volunteers to accompany children to clinic appointments.
• Patient advocacy.
• Provision of transport vouchers.

In partnership with UNICEF

Protester at the Say it loud! march in Washington. Image by Greta Hughson/aidsmap.com

Patents and intellectual property rights are still restricting access to antiretroviral therapy in middle- and low-income countries, the Washington conference was told.

The roll-out of antiretroviral therapy in poorer countries has been made possible in part due to the development of cheaper, generic formulations of a number of key anti-HIV drugs.

However, the maintenance of intellectual property rights means that medications needed for second- and third-line treatment remain prohibitively expensive. The conference also heard of the especially high cost of treatment for some middle-income countries.

Speakers at the session recommended that efforts were made to challenge patent applications to ensure access to treatment takes priority.

Edwin J Bernard of the HIV Justice Network. © IAS/Ryan Rayburn - Commercialimage.net

Draconian laws on HIV transmission and exposure were the focus of a session at the International AIDS Conference.

Delegates heard that courts often dismissed evidence regarding the excellent prognosis of patients on HIV therapy and the impact of HIV treatment on the risk of transmission.

People with HIV are being imprisoned after sexual encounters when they did not disclose their status, even when no transmission occurred. In some instances, people had been prosecuted even though the type of sex they had engaged in involved no actual risk of HIV transmission.

More encouragingly, the session was also told that lobbying could lead to changes in the law.

For instance, Denmark suspended its tough HIV-specific laws after being presented with scientific evidence about the life expectancy of people on effective HIV therapy and the impact of treatment as prevention.

Vincent Lo Re of the University of Pennsylvania. Image ©Liz Highleyman / hivandhepatitis.com

People co-infected with HIV and hepatitis C continue to have a higher risk of serious liver disease than those who only have hepatitis C.

Researchers in the US compared rates of liver disease and liver-related death between co-infected and hepatitis C-monoinfected people.

Importantly, the co-infected participants were on HIV treatment, which has previously been shown to slow the progression of liver disease.

Co-infected people were at approximately twice the risk of developing decompensated liver disease and 69% more likely to progress to liver cancer.

An undetectable HIV viral load reduced the risk of liver disease, but even with HIV suppression outcomes were still poorer in co-infected people compared to those who only had hepatitis C.

Contradictory evidence concerning the use of hormonal contraception and its possible impact on the risk of infection with HIV was presented to the International AIDS Conference.

Research published last year showed that women who used hormonal contraception had an increased risk of infection with HIV and were also more likely to transmit the virus.

A re-analysis of the results of this study confirmed the association between hormonal contraception and an increased risk of acquiring HIV.

The association between the use of hormonal contraception and HIV risk remained significant when taking into account rates of unprotected sex.

However, a meta-analysis of studies looking at the risk of HIV and the use of hormonal and non-hormonal forms of contraception failed to find any definitive evidence that hormonal contraception increased the chances of infection with HIV.

The point was made that access to reliable contraception is important for women, and that any possible HIV risk has to be balanced with the availability of effective contraception.