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A strategy to end the HIV epidemic in children and adolescents has been launched at the 21st International AIDS conference (AIDS 2016).

The strategy is intended to ensure that children and adolescents don’t get left behind in efforts to achieve the 90-90-90 target (90% of people living with HIV diagnosed, 90% of people diagnosed taking HIV treatment, 90% of those on treatment achieving viral suppression). It calls for antiretroviral therapy (ART) to reach 1.6 million children and 1.2 million adolescents within two years.

At the core of the strategy is a realisation that rolling out ART to children and adolescents has its own unique challenges.

Improving diagnosis rates is the first step. Point-of-care testing is set to become more widely available and there will be more opportunities to test outside traditional medical contexts.

ART should be provided to all children and adolescents, regardless of age and CD4 count. Simplified regimens are also a priority.

Viral suppression can be especially challenging, in part due to adherence difficulties, but also due to drug resistance. But innovations in service delivery – such as nurse-led clinics and integration of peer support – can help improve retention in care and treatment outcomes.

Delegates were told there was a moral imperative to act now.

Youth activism at AIDS 2016. Photo by Liz Highleyman, hivandhepatitis.com

New research showed the importance of taking immediate action. The conference heard that South Africa is on the verge of a “youth bulge” in its HIV epidemic. Rates of vertical transmission are falling and survival of children born with HIV is much improved. Data collected between 2004 and 2014 confirmed this shift in the demographics of the country’s epidemic, as children born with HIV in the 2000s begin to reach adolescence and HIV infections among adolescents remain high.

Young people transitioning from paediatric and youth-friendly services into adult care often have difficulties attending follow-up appointments and problems taking treatment are also common. Treatment programmes in sub-Saharan Africa were urged to plan and prepare for this growing population.

New data from the PARTNER study looking at the infectiousness of people taking virologically suppressive ART has added to confidence that individuals with an undetectable viral load are extremely unlikely to transmit HIV to their sexual partners – the risk may even be zero.

The research involves serodiscordant couples (couples in which one person is living with HIV) and is looking at the efficacy of HIV treatment as prevention. Results released in 2014 showed no transmissions after sex without a condom when the HIV-positive partner had an undetectable viral load.

The latest data were collected from 888 couples, 38% of them gay men. Each couple was followed for an average of 1.6 years.

There were eleven new HIV infections – but viral sequencing showed that, in every case, the virus acquired by the HIV-negative partner was quite different from their partner’s virus, suggesting it had been acquired outside the relationship.

The vagaries of statistical analysis mean that researchers are not yet prepared to say that an undetectable viral load means a zero risk of transmission – but that may well be the case, and the lack of any transmissions in couples – gay or heterosexual – in the context of an undetectable viral load is remarkable.

The study will last for another year with final results reported in 2018.

Photo by Greg Lomas / Scholars and Gentlemen / Médecins sans Frontières

Research appears to have substantially under-estimated the proportion of people living with HIV in South Africa who are retained in care, a key step in the HIV treatment cascade and essential to achievement of 90-90-90 targets.

Studies involving individual clinics have consistently shown that a large proportion of people drop out of care.

However, research based on individual treatment centres may not represent the true picture, as it’s usually unable to take into account people moving to another clinic.

Investigators therefore examined data collected by the South African Health Laboratory Service. It has information on over 9 million individuals, including the 3 million people taking ART.

Investigators tracked approximately 67,000 people who started ART in 2004/05.

Clinic-based records suggested that only 17% were still in care nine years later; but system-wide recording showed that 54% were actually accessing care at the nine-year follow-up interval.

Women were more likely to be retained in care than men, and overall the study shows just how common internal migration is among people with HIV in South Africa.

Julie Pannetier presenting at AIDS 2016. Photo by Roger Pebody, aidsmap.com

Migrant African women who acquired HIV after moving to France were four times more likely to have experienced sexual violence than other migrant women.

The research suggests that sexual violence is an important risk factor for migrant women acquiring HIV while living in Europe.

The research involved approximately 1000 women, all born in Africa and now living in the Paris region. They were interviewed about their life histories, exploring events before and after their migration to France.

A total of 156 women acquired HIV after moving to France; 24% had experienced forced sex, including 15% who reported that this occurred while living in France.

Women who migrated after being threatened in their country of origin, and also those without stable housing or living with family or friends were especially likely to report sexual violence.

Vulnerability to sexual violence was especially high during the first year after migration to France and at the time of sexual debut.

Separate research showed that a large number of migrants acquired HIV after moving to Europe. In Italy, Sweden and Belgium, between 23 and 29% of migrants living with HIV acquired the infection after arriving in Europe – the figure was even higher for the UK, at 43%.

Scott McCallister presenting at AIDS 2016. Photo by Jan Brittenson, hivandhepatitis.com

Data collected from pharmacies suggest that over 79,000 people started Truvada (tenofovir/emtricitabine) pre-exposure prophylaxis (PrEP) in the US during the past four years. PrEP use was especially high among gay men in large cities, with prescriptions lagging behind in other groups.

PrEP was approved in the US in 2012. Uptake was initially slow, but use increased sharply in 2013 after gay and bisexual men began promoting PrEP within their communities.

To get a clear understanding of current use of PrEP, investigators from Gilead, manufacturers of Truvada, collected data from retail pharmacies in the US that dispense the therapy.

Their survey showed that over 79,600 individuals started the treatment between 2012 and 2016.

Over 60,000 of the PrEP prescriptions were dispensed to men, and the average age of those starting PrEP was 33 years.

Five states – California, New York, Texas, Florida and Illinois – accounted for over half of all prescriptions.

The data suggest that PrEP may not be reaching some populations at especially high risk of HIV, including young black gay and bisexual men, especially those living in states in the southeast of the US.

It’s likely that these figures under-estimate the real extent of PrEP use in the US as they were unable to take account of non-prescription use.

Frances Cowan presenting at AIDS 2016. Photo by Roger Pebody, aidsmap.com

A randomised trial involving sex workers has failed to show that offering enhanced access to ART and PrEP has benefits in terms of viral load suppression.

This may be because the services and support offered to women in the control arm was already good enough to substantially improve health outcomes.

Comprehensive care and HIV prevention are rarely provided to sex workers, a group especially vulnerable to HIV.

The World Health Organization (WHO) recommends that services should include access to condoms and contraception, HIV testing and counselling, referral to HIV treatment services, management of sexually transmitted infections (STIs), and legal and peer support.

In the present study, these services were provided as standard. An intervention arm received enhanced services, including provision of ART at a specialist sex worker clinic for women with HIV, the offer of PrEP and SMS reminders to test again for women testing HIV-negative, adherence support for ART and PrEP, and enhanced community mobilisation.

The study was conducted in Zimbabwe and the endpoint was the proportion of sex workers who had a viral load that was potentially infectious – defined as above 1000 copies/ml.

The study confirmed that female sex workers in Zimbabwe have an extremely high risk of acquiring HIV.

At the start of the study, 30% of individuals in both the intervention and control arms had a viral load above 1000 copies/ml.

But during follow-up, this dropped to 19 and 16%, respectively, a non-significant difference.

Treatment cascade results were good: 80% of women in both study arms with HIV had been diagnosed; 83% of women with diagnosed HIV were on ART; and 89% of women on ART had an undetectable viral load.

There was some concern and suspicion about PrEP, but peer support from other sex workers helped to address these concerns.

Protesters on stage with dignitaries and Justice Edwin Cameron at AIDS2016. Photo©International AIDS Society/Abhi Indrarajan

The number of countries criminalising HIV non-disclosure to sexual partners is increasing, new research shows. The findings were presented at the Beyond Blame pre-conference held in Durban this week.

Globally, 72 countries and 30 US states have laws that criminalise HIV non-disclosure or transmission.

Prosecutions for non-disclosure, exposure/perceived exposure to HIV, and unintentional transmission have been recorded in 61 countries. Of these, 26 have HIV-specific laws, with other jurisdictions applying existing public health/criminal legislation.

So far, 30 countries in sub-Saharan Africa have laws criminalising HIV transmission or non-disclosure.

Fear, moral panic, stigma, and attempts by the state to restrict sexual autonomy were all identified as factors driving criminalisation.

The conference heard about the devastating personal impact of being prosecuted for non-disclosure.

Linda-Gail Bekker presenting at AIDS 2016. Photo©International AIDS Society/Steve Forrest/Workers' Photos

A trial examining the efficacy of a vaccine against HIV will start later this year, the conference was told.

The HVTN 702 study will enrol 5400 men and women in South Africa and is planned to last for four years.

The efficacy of the vaccine has already been explored in an ongoing pilot study – HVTN 100, involving 252 patients in South Africa, 42 of whom were given a placebo. The initial results show promise, producing an antibody response in all individuals and a CD4 response in over half.