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"No one should be forced into treatment," Eric Fleutelot of Sidaction. ©IAS/Marcus Rose/Worker's Photos

Following Monday’s presentation of the findings of the HPTN 052 study, a session yesterday explored some of the challenges of rolling out treatment-as-prevention programmes.

One difficulty, highlighted by Professor Julio Montaner from the University of British Columbia, Canada, is the proportion of people with HIV who don’t yet know their HIV status. There are significant challenges in developing and delivering healthcare programmes that engage and retain people from the point of HIV testing, through taking up care and starting treatment, to ensuring long-term adherence.

One view emerging at the conference is that it is unethical not to offer treatment to the HIV-positive partner in a serodiscordant couple (a couple in which one partner has HIV and the other does not). But there is no consensus on this view, with other people saying that, in some parts of the world, the numbers of serodiscordant couples will be far outweighed by people in other situations, including those with undiagnosed HIV.

And the issue of human rights will need to be carefully considered, with the needs of people with HIV at the centre of thinking and planning about the role of HIV treatment in prevention.

“Every individual with HIV should decide for themselves when and how to start treatment,” Eric Fleutelot, director of international programmes for Sidaction, said. “No one should be forced or coerced into treatment primarily for the benefit of the public health rather than the health or the wellbeing of the individual.”

The World Health Organization will be organising a panel to look at the role of antiretrovirals for treatment and for prevention, over the next year, and to develop international guidance.

People who started HIV therapy in the Cameroon increased their level of sexual activity and engaged in more unprotected sex, a study presented to the Rome conference shows.

However, investigators think that the reduction in the study participants’ viral load cancelled out the apparent increase in risk behaviour.

Inconsistent condom use was reported by 40% of people six months after starting HIV therapy, but this had increased to 55% after two years.

But the impact of therapy on viral load and infectiousness helped compensate for increases in sexual risk.

The investigators calculated that treatment reduced an individual’s risk of transmitting HIV by 86% after six months of therapy and by 89% after two years of treatment.

Images from presentation by Anandi Sheth of Emory University School of Medicine, Division of Infectious Diseases, Atlanta, United States

A small US study has found that HIV-positive women taking stable antiretroviral therapy have good drug concentrations and low levels of HIV in the genital tract.

The 20 women in the study were taking ritonavir-boosted atazanavir (Reyataz) with FTC/tenofovir (Truvada), and had been treated with antiretroviral therapy for an average of 14 months.

They were monitored intensively over a four-week period, therefore ensuring that samples were taken throughout the menstrual cycle.

Antiretroviral drugs levels were higher in genital fluids than in blood – concentrations of FTC were 12.2 times higher, tenofovir 3.4 times higher, and atazanavir 2.5 times higher.

Good levels of treatment adherence were reported, and this was reflected in the high levels of HIV suppression found in both blood and the genital fluids.

But cell-free HIV was detected in 16% of samples of genital fluid – it’s possible that this is an infectious level.

Nevertheless, the investigators believe the study provides further evidence that effective antiretroviral therapy reduces infectiousness.

Image by Greta Hughson (aidsmap.com)

Patients co-infected with HIV and herpes simplex virus-2 (HSV-2) have slower disease progression if they take daily aciclovir, a new study has shown.

The research was conducted in the Rakai district of Uganda and included people co-infected with HIV and HSV-2 who were not yet eligible for antiretroviral therapy according to local guidelines (having a CD4 cell count below 250 or being ill because of HIV).

They were randomised to receive either 400mg of aciclovir twice daily or a placebo.

The study lasted two years and the investigators compared the proportion of people in each group who needed to start HIV therapy because of either a fall in their CD4 cell count or the development of an AIDS-defining condition.

Patients treated with aciclovir were 27% less likely to start antiretroviral therapy than those in the placebo arm.

The benefits of aciclovir therapy were especially pronounced for patients with a viral load above 50,000 copies/ml at the start of the study.

A modest fall in HIV viral load was observed in the aciclovir-treated patients, but viral load increased among those taking the placebo.

The researchers concluded “aciclovir 400mg twice daily delayed disease progression among HIV/HSV-2 co-infected individuals,” adding that “[aciclovir] treatment of chronic HSV-2 infection may be warranted in HIV-infected individuals”.

The rates of mother-to-child HIV transmission in South Africa has fallen to under 4%, data presented to the conference show.

The country’s programme to reduce vertical (mother-to-child) HIV transmission has been running for nine years.

The dramatic reduction in transmission rates is due to the implementation of a comprehensive national programme involving antenatal HIV testing and provision of antiretroviral treatment for mothers and infants.

A third of HIV-positive mothers received triple-drug antiretroviral therapy, 62% of mothers did not breastfeed and 20% reported exclusive breastfeeding.

Overall, the national rate of mother-to-child transmission at four to eight weeks was 3.5%.

Images from presentation by Elizabeth Reddy of Duke University Medical Center, Durham, United States

A study that involved people with HIV encouraging their friends and relations to test for the virus has helped to detect previously undiagnosed infections.

The small pilot project was conducted in rural Tanzania.

As part of the scheme, seventy-five HIV-positive people who received care at a local treatment centre were given vouchers to distribute to their friends and contacts encouraging them to have an HIV test.

A total of 41 contacts came forward for testing and 13 were diagnosed with HIV.

Dr Steven Reid of Imperial College, London. Image by Theo Smart (aidsmap.com)

Point-of-care monitoring performed by a nurse can provide people with a CD4 cell count while they wait, delegates to the Rome conference were told.

CD4 cell count monitoring plays an important role in HIV care. However, tests usually require laboratory equipment and specially trained staff.

A new generation of CD4 cell count tests has been developed that can provide point-of-care monitoring with results in as little as 20 minutes.

Mathematical modelling suggested that the new tests could be cost-effective in many resource-limited settings, but this would depend on the volume of patients being monitored.

A combination of raltegravir (Isentress) with lopinavir/ritonavir (Kaletra) is associated with good preservation of bone density over two years, research has shown.

Investigators compared the impact of this regimen on bone density with a traditional three-drug combination comprising FTC/tenofovir (Truvada) with Kaletra.

One of the hottest topics in HIV research is the impact of antiretroviral therapy on bone density, and there is particular concern that tenofovir may be especially associated with bone loss.

The raltegravir/Kaletra combination was just as effective as the Truvada/Kaletra regimen in controlling HIV.

After two years of treatment there was little change in the bone density of patients taking the raltegravir/Kaletra combination. In contrast, significant falls in bone density were observed in the patients treated with tenofovir.

People taking raltegravir/Kaletra were much less likely to have a 5% reduction in their bone density than people taking the Truvada-based regimen.

The researchers believe that this finding is of clinical significance, noting “the decreases observed in the lopinavir/ritonavir plus tenofovir/FTC group are similar in magnitude to the bone mineral density losses observed during the first two years of menopause.”

A low baseline CD4 cell count, a high viral load, and low body mass index (BMI) were also associated with increased bone loss.

Women's Prevention Revolution demonstration. Photo©IAS/Steve Forrest/Workers' Photo

Caspar Thomson, NAM's Executive Director, feels there's a buzz of optimism and excitement in Rome as the potential for HIV prevention is explored.

But, as Michael Sidibé, UNAIDS’s Executive Director, cautioned as the event began, “We have to remember that history will judge us not by our scientific breakthroughs, but how we apply them.”

Read more in Caspar's blogpost on our website.