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Patients who start HIV treatment when their CD4 cell count is between 350 and 500 cells/mm³ have better outcomes than people who initiate therapy when their CD4 cell count is 350 or below, a study has shown.

However, the research also demonstrated that starting treatment with a CD4 cell count above 500 gave no additional advantage.

The CASCADE study involved over 9000 patients, recruited within six months of their infection; none had AIDS, nor had any started HIV treatment.

Patients were followed for an average of five years, comparing progression to AIDS and death on and off treatment. Approximately 9% progressed to AIDS and 6% died.

For patients with a CD4 cell count between 200 and 350, starting treatment reduced the risk of AIDS or death by about 40%.

Benefits of treatment were also clear for those starting treatment when their CD4 cell count was between 350 and 500.

But the risk of AIDS or death was low for patients with a CD4 cell count above 500, regardless of whether or not they took antiretroviral drugs.

Igor Grant from the University of California at San Diego. ©IAS/Steve Forest/Workers' Photos

Having a low nadir (lowest-ever) CD4 cell count increases the risk of neurocognitive impairment, even if a patient responds well to antiretroviral treatment.

US researchers from the CHARTER study looked at the risk factors for neurocognitive problems in 1500 patients with HIV.

Approximately half of the study participants showed some sort of impairment.

The investigators saw a consistent relationship between lowest-ever past CD4 cell count and presence of impairment.

Preventing severe immunosuppression by starting treatment earlier "may lead to more favourable neurocognitive outcomes", argued the researchers.

Combining the protease inhibitor atazanavir (Reyataz) with the integrase inhibitor raltegravir (Isentress) or the CCR5 inhibitor maraviroc (Celsentri or Selzentry) has a good anti-HIV effect.

But there is some concern about possible side-effects and the development of resistance.

The SPARTAN study involved 94 treatment-naive patients, randomised to receive either atazanavir boosted by ritonavir, plus Truvada (FTC and tenofovir), or unboosted atazanavir with raltegravir.

After 24 weeks, 75% of patients taking atazanavir/raltegravir had an undetectable viral load, compared to 63% in the other arm.

Some patients were followed for 48 weeks, when 82% of the patients taking atazanavir/raltegravir and 76% of patients taking the other regimen were undetectable.

Resistance to raltegravir emerged in a small number of patients whose viral load was not suppressed.

CD4 cell increases were slightly better amongst the patients in the raltegravir arm.

Overall rates of side-effects were similar.However, those taking atazanavir/raltegravir were much more likely to experience a build-up in bilirubin and therefore to stop treatment.

The A4001078 study involved 121 patients randomised to take either boosted atazanavir with maraviroc or atazanavir/ritonavir with Truvada.

After 24 weeks, 80% of those taking atazanavir/maraviroc had an undetectable viral load, compared to 89%.

A study involving US gay men suggests that pre-exposure prophylaxis (PrEP) using tenofovir (Viread) is safe.

The study involved 373 men; 86% completed the two-year study.

Divided into four groups, the first two groups were randomised to receive either tenofovir or a placebo; treatment lasted for two years. Men in the other two groups were monitored for six months and then started treatment with either tenofovir or a placebo. These delayed-treatment arms were to see if taking PrEP increased sexual risk behaviour.

There was no real difference in side-effects reported by patients taking tenofovir or the placebo, other than greater reporting of back pain from those on tenofovir.

Encouragingly, there was no evidence that tenofovir affected kidney function, or caused bone loss.

Sexual risk behaviour did not increase during the trial.

Seven men became HIV-positive during the study: none of them were taking tenofovir.

But the researchers emphasised that their research didn’t have the statistical power to show whether PrEP was effective.

Activist Mark Heywood. ©IAS/Marcus Rose/Workers' Photos

A campaign to test 15 million people for HIV in one year in South Africa is being marred by coercion, and may end up of little value because of a lack of effective monitoring procedures, the conference was told.

South Africa aims to provide antiretroviral therapy to 80% of those who need it by the end of 2011.

Many HIV infections are undiagnosed, so accompanying this treatment drive is a mass testing campaign. The health ministry estimates “about a million” people have been tested for HIV since April.

Activist Mark Heywood called the testing campaign justified and needed, explaining that not only was it acting as a gateway to HIV treatment and care, but also providing screening for other illnesses and strengthening health systems.

But he also expressed concerns, especially about human rights. “There is no system to monitor whether a person who is diagnosed with HIV then suffers discrimination, suffers violence or gains access to treatment,” he said.

Furthermore, Heywood was doubtful that all those diagnosed would receive treatment.

There was heated debate during the session, with one delegate saying: “I am so troubled that HIV counselling and testing continues to be the place that people want to put a gate...before letting people access care…there is no other disease that we have made a big deal over...diagnosis.”

Approximately 16% of gay men diagnosed with HIV in the UK in 2009-10 were recently infected.

Health Protection Agency (HPA) investigators analysed 2099 blood samples from people testing HIV-positive between February 2009 and May 2010, using the 'Recent Infection Testing Algorithm'.

They found that 16% of gay men diagnosed with HIV had been recently infected, compared to 6% of heterosexual men and 7% of heterosexual women.

Recent infections in heterosexuals were largely amongst people born in the UK. African heterosexual people tended to be diagnosed with chronic HIV infection.

Images from presentation by Kimberly Powers.

HIV prevention initiatives need to reach both those with chronic HIV, and patients recently infected, research from Malawi showed.

Even if it proved possible to reach 75% of patients with long-term HIV infection, this would not halt the epidemic, argued the researchers.

They therefore emphasised the need to also target those recently infected, who are potentially very infectious as viral load is especially high soon after infection.

Researchers estimated that 38% of new HIV transmissions in Lilongwe, Malawi, could be attributed to people recently infected.

Researchers calculated that, if effective HIV prevention interventions reached 75% of those recently infected, HIV prevalence in the country could be reduced from its current level of 14% to 8% by 2030.

If effective prevention could reach 75% of people in chronic infection and 50% of people in early infection, prevalence would drop to about 1% by 2030.

“Our results suggest that it is time to determine the best ways to identify early index cases and the optimal prevention strategies to initiate during early HIV,” said a researcher.

Shona Schonning of the Eurasian Harm Reduction Network. ©IAS/Marcus Rose/Workers' Photos

In this region, 89% of national government funding for HIV prevention goes on general population programmes, although most countries’ epidemics are dominated by injecting drug use, the conference was told.

Speakers called upon the Global Fund to continue supporting prevention programmes in Russia amongst other countries. They believe that the Russian government is unwilling or incapable of responding to the country’s HIV epidemic.

Without international support, the prevention needs of vulnerable groups will be ignored and treatment stock-outs will become more frequent.

Eastern Europe and Central Asia now has the fastest growing HIV epidemic in the world. HIV prevalence is above 1% in the general population of Russia and Ukraine, and exceptionally high in injecting drug users.

Moreover, only 23% of people who need antiretroviral therapy receive it.

Nora Volkow of the US National Institute on Drug Abuse. ©IAS/Marcus Rose/Workers' Photos

HIV and drug use

Drug policies based on ideology rather than science are fuelling human rights abuses of drug users, according to a panel of experts at the conference.

In a separate session, delegates heard that drug use in and of itself is linked to increased rates of HIV transmission, supporting evidence that substitution therapy programmes could help to stem the HIV epidemic.

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HIV and prisons

A panel at the conference recognised the dire level of health need among prisoners and the slow progress being made towards prison health reform.

Most countries have implemented few or no harm-reduction programmes for people in prison, providing next to no protection for those involved in risky behaviours such as needle-sharing and unprotected sex.

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