POZ in Madrid: Notes from the 11th European AIDS Conference
by David Evans
Madrid’s charm—from its narrow winding cobblestone streets to the abundant plazas filled with old-world taverns and sumptuous restaurants—proved to be the ambiente perfecto to learn the latest in HIV research at the 11th European AIDS Conference (EACS). This biennial gathering of researchers from across Europe and the globe, which took place from October 24 to 27, offered critical updates on everything from the latest experimental HIV treatments to the recent trials and tribulations in prevention research. Here we report some highlights from EACS, with links to more complete coverage on AIDSmeds.com.
Continental Shift The organizers kicked off this year’s conference with the release of new European HIV treatment guidelines, reflecting a few key changes:
Older European guidelines recommended that treatment be started when the CD4 count falls below 200. Now patients are being urged to start earlier, when CD4s fall below 350, on a par with U.S. guidelines. The reason: data showing that patients with CD4s between 200 and 350 not on therapy are at a higher risk for heart disease and certain cancers than those who are on treatment.
With the arrival of new drugs—and new classes—that are active against drug-resistant HIV, the revised European guidelines stress that undetectable virus should be priority No. 1, even for patients with a lot of treatment experience under their belts. The authors recommend treatment-experienced patients initiate a new regimen that includes at least two drugs to which their virus is very likely to respond.
Protecting Body and Mind While it may have some downsides, antiretroviral (ARV) treatment certainly has an upside—it works. Added to the long list of studies confirming the life- and health-extending benefits of HIV treatment were three intriguing reports in Madrid:
More than half of patients who started triple-drug treatment with profoundly suppressed immune systems back in 1996 are still alive—and doing quite well—according to long-term follow-up data from the Belgian PICASSO cohort. Of those that started with an average CD4 count of 26, approximately 52 percent are alive and accounted for 10 years later, 70 percent of them with undetectable viral loads and CD4s above 350.
Chances of an immune system boost are good when ARV therapy is used for an extended period of time, according to new data from the U.K. CHIC cohort. Among patients who kept their viral load undetectable for at least five years, gains in CD4s were robust—no matter what their CD4 count was when they started treatment.
People with hard-to-treat central nervous system (CNS) complications of HIV also benefit from ARV treatment. Following the introduction of combination therapy in 1996, a French study found, survival after a diagnosis of a serious AIDS-related brain illness—like toxoplasmosis or dementia—increased by roughly 100 percent.
Defining and Developing Drug Options New data from clinical trials not only helps to advance novel ARVs in development, but redefines the use of agents already with us:
Final 48-week data from the second of two Phase III studies of Pfizer’s Selzentry (maraviroc) were reported. After 48 weeks of treatment in the MOTIVATE 2 study, Selzentry was more than twice as likely as a placebo to get heavily treatment-experienced people to undetectable viral loads, without additional side effects.
Twice-daily Kaletra may have advantages over once-daily dosing. One study, comparing it with boosted Reyataz (atazanavir), found that blood levels of the drug fell to low levels using once-daily dosing, potentially paving the way for drug resistance and treatment failure. A second study found that patients starting therapy with high viral loads—above 100,000 copies—faired better using boosted Prezista (darunavir) or twice-daily Kaletra, compared with those using once-daily Kaletra, in keeping their viral loads undetectable. Both studies had limitations, however, so additional once-daily-Kaletra research is needed.
The study of Kaletra monotherapy—using the protease inhibitor sans other ARVs—continues. Starting treatment by using Kaletra alone didn’t work as well as triple-drug treatment. But for those who got their viral loads undetectable after first using standard combo therapy, making the switch to Kaletra-only worked well for almost three years.
Boosted Invirase (saquinavir) is comparable to Kaletra in terms of viral load reductions after 48 weeks, according to final data from the GEMINI study. And while boosted Invirase resulted in fewer triglycerides increases, it was more likely to raise “bad” LDL cholesterol, compared with Kaletra.
Currently in the pipeline is rilpivirine (TMC278), Tibotec’s second-in-line non-nucleoside reverse transcriptase inhibitor (etravirine is the first). It worked just as well as Sustiva (efavirenz) at keeping viral loads undetectable in treatment first timers for 48 weeks but without many of the pesky CNS side effects like dizziness and vivid dreams often experienced by Sustiva users.
Rash Decisions With the promise of ARV treatment also comes the risk of side effects. New data presented at EACS explored available—and evolving—options to prevent and reverse common adverse events.
Skin rashes may be more likely to occur among those using 400 mg Viramune (nevirapine) once a day, compared with those using 200 mg twice a day, the recommended dose in the U.S.
For people with elevations in cholesterol, particularly LDL, a head-to-head comparison of two popular “statins” suggests that Crestor (rosuvastatin) is better than Pravachol (pravastatin) at getting levels out of the red and back into the black.
For lipo sufferers, Theratechnologies’ tesamorelin was shown to be safe and effective at reducing abnormal fat deposits in the gut area when continued for a year.
Kid Care For HIV-positive adults, ARV advances have been rapid and revolutionary. Not so much for the world’s 2 million children with HIV.
In a video interview, Jose Ramos, MD, explains why many HIV-positive children are not receiving HIV treatment and why pediatric options are few and far between.
For kids who can swallow pills—and want to avoid the alcohol-based and unsavory liquid version of the drug—Abbott has made headway with the development of a lower-strength Kaletra tablet. It achieves necessary drug concentrations in the blood, and researchers have come up with a weight-based dosing schedule.
Prevention Attention The state of prevention research was the theme of one key session at the conference:
Despite disappointing results from trials of Merck’s Ad5 candidate, vaccine expert Giuseppe Pantaleo, MD, stressed that other candidates in the pipeline hold promise.
Other biomedical strategies, such as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) using existing ARVs, have demonstrated some degree of effectiveness. Results from larger trials are expected soon.
Male circumcision may be a cut above the rest, reducing the risk of HIV transmission in some studies up to 60 percent. Experts are now urging its implementation in sub-Saharan Africa.
Valerie Stone, MD, gave AIDSmeds the lowdown on safer procedures for mixed-status couples looking to become pregnant, along with the best practices to reduce the risk of HIV-positive pregnant women passing the virus on to their babies.
Beth Benne, RN, is HIV negative, but
the virus has impacted her life. She currently supervises a biannual HIV/AIDS awareness week as
the director of the student health center at Pierce College, a
community commuter school in Woodland Hills, California.
Woman of the Month is supported by exclusive advertising from Gilead.
Overheard in the Women's Forum
"I recently met a guy who is negative. I did tell him about my status and he decided to kiss me anyway (we didn't go further than that). But a day later, he called and said that he actually had a mouth ulcer that time when we kissed and he was very worried. Asked if he can get the virus from me that way. For that moment, I felt so insulted and yet I felt so bad. It was my first time having a contact with a "negative" guy."
