Join 3,440 readers in helping fund MetaFilter (Hide)


33 years and counting
March 14, 2014 8:53 AM   Subscribe

The Conference on Retroviruses and Opportunistic Infections ended on March 6 And the news coming out of it was astounding. 33 years after the first cases were described, researchers are genuinely excited about where we are and where we are going.

Last year's news noted that analysis from the SMART and ESPRIT studies found that among virologically suppressed, ART-treated subjects with CD4 cells greater than 500, there was no evidence of a higher mortality rate compared to the general population. Not to be outdone, this year's reports were equally exciting.

An integrase inhibitor is showing promise as a potential pre-exposure prophylaxis (PrEP) drug that could be injected once every three months to prevent HIV infection. It is not yet in human clinical trials, though that could happen within two years.

Treatment as Prevention or TasP, as a means of preventing HIV transmissions made a huge leap forward with a study showing that among serodiscordant heterosexual couples transmission was virtually eliminated when the partner with HIV was virologically suppressed.

Gene therapy has become more promising every day but in terms of actual uses in the real world, we are a long, long way off.

Paul Sax, M.D., author of HIV and ID Observations Blog for NEJM notes that while we can look at new antiretrovirals with fewer side effects, antiretroviral medications are now at a point that HIV therapy cannot be improved virologically because we are really at optimal virological suppression.

And outside of CROI, today's news shows that HIV related disease is no longer among the top ten causes of death in New York City. Though African American and Latino men who have sex with men still are disproportionately represented among people infected with HIV and those still dying of HIV-related causes.
posted by Sophie1 (31 comments total) 37 users marked this as a favorite

 
This is all great news. Now let's get the HIV criminalization laws off the books, please.
posted by roomthreeseventeen at 9:37 AM on March 14 [12 favorites]


Thanks, Sophie1 for your compilation.

The most promising seemed to be the long acting integrase inhibitor. GSK744 has a half-life of 40 hours. It can be given in a depot preparation which extends its virtual half-life to 40 days. If it can be given to high-risk people, maybe it would be as good as a vaccine (alright, a vaccine you have to give every six weeks - approximately because half-life doesn't mean falling below the active threshold.) The research is in animals, however, which have an entirely different HIV infection dynamic.

My rule of thumb in research: 90% of can't miss prospects fail. 50% of absolutely can't miss prospects fail. Still we move on.
posted by dances_with_sneetches at 9:41 AM on March 14 [1 favorite]


It isn't a crime to have HIV. Is this whole post designed to suggest that it's now okay to expose someone to HIV without their knowledge?
posted by Dasein at 10:00 AM on March 14


The "Gene Therapy" link to the Wall Street Journal seems to be paywalled. Can anyone suggest another source, or point to a summary? (Failing that, what's the WSJ's cancellation policy like? I don't mind paying to read the article if it's good, but don't want to end up trapped in a months-long subscription)

Superb post Sophie1, thanks!
posted by metaBugs at 10:02 AM on March 14 [1 favorite]


Yeah I dunno. Given what I understand to be some big outstanding question marks, PreP still seems iffy as a policy focus. I don't think it is ethical to act as if PreP eliminates or reduces the need for safer sex practices, given the current state of ignorance.
posted by PMdixon at 10:05 AM on March 14


It isn't a crime to have HIV. Is this whole post designed to suggest that it's now okay to expose someone to HIV without their knowledge?

That seems a really weird reading of the post; I think perhaps you're reading the first comment as if it were part of the FPP?
posted by yoink at 10:20 AM on March 14 [5 favorites]


One of the things that's fascinating to me is how in certain gay populations (SF, maybe NY) everyone seems to be on PrEP, and elsewhere in the US, most guys still haven't heard of it.
posted by roger ackroyd at 10:22 AM on March 14


in certain gay populations (SF, maybe NY) everyone seems to be on PrEP, and elsewhere in the US, most guys still haven't heard of it.

Raising awareness is sometimes actually genuinely useful.
posted by jaduncan at 10:25 AM on March 14 [4 favorites]


For anyone else interested in the gene therapy angle (my personal hobby horse, sorry), there are nice write-ups of a recently published HIV gene therapy trial on NHS Health News and the graun. As Sophie1 said, the data seem promising but it looks a long way from being a viable treatment.
posted by metaBugs at 10:29 AM on March 14 [2 favorites]


PrEP is an acronym for Pre-Exposure Prophylaxis.
posted by vapidave at 10:32 AM on March 14


Is this whole post designed to suggest that it's now okay to expose someone to HIV without their knowledge?

That's what you get from this? Multiple-link roundup of HIV/AIDS treatment findings and that's your takeway from the post?

This is great, Sophie1 - thanks for this. I've been kind-of following along at home/work, thanks to friends and colleagues (and a partner) who are deep in the world of HIV health policy, and it's cool to have a bunch of links all in one place instead of scattered across emails and fb.
posted by rtha at 10:38 AM on March 14 [12 favorites]


roger - even in NYC many people haven't heard of it. Health literacy in general is lower in the Bronx (correlates with socio-economic status).
posted by Wretch729 at 10:42 AM on March 14


rtha, read the first comment by the OP, which rather colours the post.
posted by Dasein at 10:55 AM on March 14


Dasein: the first comment by the OP where? I don't see one here.
posted by edd at 10:58 AM on March 14


rtha, read the first comment by the OP, which rather colours the post.
posted by Dasein at 10:55 AM on March 14 [+] [!]


Yeah.

Or maybe some people showed up to the post with tinted lenses and found "colour".

That's also an option, don'tcha think?
posted by Pirate-Bartender-Zombie-Monkey at 11:00 AM on March 14 [2 favorites]


Dasein, I believe that Sophie1 is the OP, but roomthreeseventeen is the first commenter. Sophie1's post makes no mention that I can see about HIV criminalisation/decriminalisation.
posted by fanlight at 11:05 AM on March 14 [2 favorites]


[Yes, the poster has not actually made any comments in this thread. Let's maybe rewind here and talk about the content of the post?]
posted by cortex at 11:08 AM on March 14 [2 favorites]


I work (as a print/web designer) at a non-profit that supports programs that do HIV research. I know a lot of our scientists were presenting at CROI, so thanks for the reading material Sophie1.

From what I've observed through the materials we design and publish working here, it really does seem like we have all the tools in our arsenal that are needed to beat this thing. PrEP and TaSP; very effective vertical transmission prevention (mother-to-child); and a promising vaccine with a 60% efficacy at 1 year. If we can just work out the human, commercial, governmental aspects of this we could have HIV infections end in a generation.

And while yes, it is not a crime to have HIV, it is still a crime to expose someone to it. This really does need to be examined as the mortality rate of HIV falls to be comparable to say, Hep C, which has never been criminalized.
posted by fontophilic at 11:45 AM on March 14 [9 favorites]


For anyone curious about PrEP, I find this site from the SF AIDS Foundation to be incredibly useful.
posted by roger ackroyd at 1:13 PM on March 14


An integrase inhibitor is showing promise as a potential pre-exposure prophylaxis (PrEP) drug that could be injected once every three months to prevent HIV infection. It is not yet in human clinical trials, though that could happen within two years.

Whoa. That sounds amazingly cool. The sound you just heard was the last five men in Toronto who still use them throwing away their condoms.

This is all great news. Now let's get the HIV criminalization laws off the books, please.

When there is universal access to vaccination/PrEP for the uninfected, and equal access to medication that works, maybe.

Until then I am perfectly fine with the idea that exposing someone to HIV without their explicit consent is a crime.
posted by feckless fecal fear mongering at 1:34 PM on March 14 [4 favorites]


The "Gene Therapy" link to the Wall Street Journal seems to be paywalled.

Copy and paste the headline into Google works much of the time (for the WSJ that is).
posted by dhartung at 3:47 PM on March 14 [1 favorite]


Here are my personal thoughts on PrEP in case anyone cares: I have been working in HIV going on a quarter century now. Since about 1992, infection rates per year haven't changed significantly. Could we be doing better at providing prevention education? Absolutely, but what we're doing is not bringing down infection rates enough.

Second: in the U.S. and other western countries where the epidemic seems concentrated in MSM communities, men are not using condoms. Every day, all the time for a billion different reasons. Some of those reasons may make sense to you, some of them may not, but it doesn't matter because it's happening. If there was something we could add that would make prevention easier, why wouldn't we?

In injection drug using communities, HIV has been on the way down. Why? It's not because fewer people are using, in fact more people on Western countries are using than they were in the early days of the epidemic. Rates are lower because we provide clean needles and methadone. Risk reduction.

I am not comparing heroin addiction to sex. On the contrary. There are far better reasons to have sex unprotected than use needles. One of them is I hear it feels amazing to be that intimate with the person you love. Other reasons? Survival sex, a mistake, young, drunk, or high. It happens. But for a young gay man in a major metropolitan area, it's not supposed to happen. Ever. No mistakes and your sexuality, something that makes you feel alive, is supposed to be scary, deadly, never spontaneous and always, always careful. Not only does it suck, make you hate and fear your own libido, but it also makes you desperate, or at least a little curious to see what the fuss is about. But then you get shamed by your own community for seroconverting.

What a hideous mess that is. So provide another option. Another tool. That tool is out there and it works. /rant
posted by Sophie1 at 4:19 PM on March 14 [13 favorites]


I'll be less subtle:

The anti-PrEP high horse is trampling kids to death.

PrEP prevents HIV transmission. This is a goddamn miracle.

The people opposing PrEP are every bit as bad as the ones who stalled the public health response to the epidemic in the 1980s, and are every bit as complicit in every new infection and death. The end of the HIV/AIDS epidemic is within our grasp, and I will not. fucking. tolerate. anybody who stands in the way of that, or isn't willing to accept anything less than a perfect cure.
posted by schmod at 4:37 PM on March 14 [13 favorites]


Shit schmod. I could not favorite that comment hard enough.
posted by Sophie1 at 4:54 PM on March 14


There's also some really fascinating basic biology coming out that appears to solve one of the major longstanding mysteries about HIV, which is understanding why T cells actually get so depleted post-infection. Counterintuitively, HIV actually doesn't productively infect the majority of T cells, so it's been a long-standing puzzle why it eventually wipes them out if left unchecked. It turns out that this is probably not due to the virus killing the cells itself, but instead happens when a failed infection causes the T cell to self-destruct in an unusual pathway called pyroptosis. Crazily enough there is already a drug approved to interfere with pyroptosis in humans; since we know the drug is reasonably safe already, it's getting fast-tracked for clinical trials.

It could be a really useful adjunct therapy, and it seems (at least to me) that it might be less likely to face trouble with resistance because it doesn't target a viral protein.

Disclaimer, I work near, but not with, some of these investigators
posted by en forme de poire at 6:45 PM on March 14 [7 favorites]


Can I ask a really dumb question? This year we hope to hire an HIV peer counsellor to get all our families (at risk for child trafficking, urban poor in Cambodia) screened as we're pretty sure we have way more HIV+ families than the 2-3% we're aware of now. A lot of the family members are women who are sex workers. Condoms are easily available, but there's a lot of pressure not to use them for economic and social reasons.

I've been reading about PrEP and I can't quite figure out - is this a difficult drug to take? Is it going to end up coming out to the developing world the way the regular HIV treatment cocktail is? Would it help a female sex worker having multiple unprotected sex? What I've read makes it seem like it works for men who have occasional exposure, and it's pricey.

I know it won't come soon, but the idea that some day there might be a pill these women could take that would keep them safe is AMAZING. Is that plausible at all? Sorry for the idiocy of the question, we don't directly deal with HIV, except for screening and social support.
posted by viggorlijah at 7:30 PM on March 14


Truvada, currently the only drug approved for PrEP in the U.S. was approved for use in people with HIV in Cambodia in February 2010. It is the exact same drug. There are issues that need to be taken into account though. Prescribing Truvada must be done in combination with an absolute HIV negative status and it is really important to have kidney function tested in case there are side effects. But for sex workers who have access to semi regular kidney function testing, it is an amazing option. Especially when condoms aren't feasible. I'm typing on my phone right now but when I get to a computer, I'll send you more information. Essentially, not just plausible but quite possible. In fact many large scale trials have been done in Thailand with some success.
posted by Sophie1 at 8:24 PM on March 14 [2 favorites]


En forme de poire, that is super cool. Not sure how I missed that article but I'm looking forward to the trials. Also, pyroptosis. Cool.
posted by Sophie1 at 8:31 PM on March 14


PrEP prevents HIV transmission. This is a goddamn miracle.

And yet, in most of the religious myths found around the world, miracles have a tendency to extract their pound of flesh in return. And I'm not talking about the projected 11k annual cost of buying a year's worth of Truvada.

I don't want to make myself any more infamous around here, but I'm a little bone-weary of reading these glorified, self-congratulatory press releases.

I really don't want to be that guy, as I generally don't see myself as resembling Matthew McConaughey in Dallas Buyers Club in any other context, but I would never prescribe Truvada to a patient for the sole reason of pre exposure prophylaxis unless they were already in a relationship with a confirmed HIV+ partner.

Anti-retrovirals are some really nasty shit when it comes to side effects. It's like someone took a long, hard look at the scorch-the-earth drugs we use during anti-cancer chemotherapy and said hey, that's pretty cool, let's see what else we can make like that.

Granted, I'm kind of a quack when it comes to the practice of medicine, since I object philosophically to the the idea of prescribing drugs to a healthy person. I still do it all the time.

But just glossing over the drug company's self-reported side effect statistics (which that they were allowed to cherry pick from any number of drug trials that they ran themselves, and then later submitted the best one to the FDA for approval) more than one in ten of the people in the trial reported medically significant degrees of nausea, dyspepsia (not very scary until you've had it), vomiting, diarrhea, inflammation of the nose, throat, sinus tracts, liver, cough, fatigue, insomnia, dizziness, nightmares, rash, depression, clinically significant and notable decrease in white blood cells, anemia, cough, minor respiratory infections, pneumonia, shortness of breath, headache, weakness, medically significant signs and symptoms of kidney damage, electrolyte changes (unrelated to the former), 2X spikes in blood sugar, early signs of osteoporosis, and urinary tract inflammation.

Now the typical, education response to that above statement is that hey, it's a drug trial. Every drug trial has a laundry list of side effects that generally includes everything under the sun. Most people don't get them. It's worth it (it being whatever the drug prevents/cures).

But those effects listed above were found in more than one in ten people in the trial. To me, that's unheard of, and I would have a real crisis in conscience if someone came into my office and said, "Hey doc, I'd like to be put on this hot new pre exposure prophylaxis I've heard so much about; I don't have HIV but I think I'm at risk because I don't like to bother with condoms."

Granted, the medical community at large would probably get on board with Truvada really quickly as soon as I get sued for malpractice because that guy ends up later being the reverse lottery winner in an ultra low risk demographic that ends up contracting HIV. But on the other hand, the side effects of this one drug that you're supposed to take for years at a time constitutes the bulk of the complaints that I see on any given day during my medical practice. That means that any one of these things generally affects the quality of life of that patient to the degree that they think "Hey, this could be serious. I should see a doctor."

As the saying goes, nobody ever got fired for buying IBM. Even when it's clearly not the best decision.
posted by hobo gitano de queretaro at 6:08 AM on March 15 [1 favorite]


Sorry - I just couldn't let this stand alone.

I'm not talking about the projected 11k annual cost of buying a year's worth of Truvada.

Which is covered by insurance.

glorified, self-congratulatory press releases.

Or peer-reviewed manuscripts, whatever.

more than one in ten of the people in the trial reported medically significant degrees of nausea, dyspepsia (not very scary until you've had it), vomiting, diarrhea, inflammation of the nose, throat, sinus tracts, liver, cough, fatigue, insomnia, dizziness, nightmares, rash, depression, clinically significant and notable decrease in white blood cells, anemia, cough, minor respiratory infections, pneumonia, shortness of breath, headache, weakness, medically significant signs and symptoms of kidney damage, electrolyte changes (unrelated to the former), 2X spikes in blood sugar, early signs of osteoporosis, and urinary tract inflammation.

And 9 in 10 didn't, so we should definitely not prescribe this. Right?

because I don't like to bother with condoms.

This is such an oversimplification of the issue and so condescending I don't even know where to start.

that you're supposed to take for years at a time

Or, just a phase in your life when you're having risky behaviors.

Ultimately, I hope none of my patients ever runs into as condescending and narrow-minded a physician as you seem to be.
posted by Sophie1 at 7:43 AM on March 17 [3 favorites]


I haven't oversimplified anything at all. You have quoted me out of context in order to oversimplify what I was saying, however. We have an enormous problem in this country with medical overkill, it has bankrupted and/or otherwise harmed millions of people. I understand this topic is your project, but you seem to be having a different conversation with someone else.

As I originally stated, this directly addresses an issue with sizable amounts of grey area, and I was outlining an ethical dilemma I have reconciling the two arguments of primum non nocere and preventing a truly devastating, but rare, illness.

In return, you insulted me quite deliberately, even going so far as to invoke Burnett's law.

Where I am located, Truvada is not covered by any insurance for pre-exposure prophylaxis. I can say that with some certainty, as I just checked.
posted by hobo gitano de queretaro at 11:27 PM on March 17


« Older "Yes?" she asked me, and the tone of her voice cal...  |  The William Jefferson Clinton ... Newer »


This thread has been archived and is closed to new comments