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HIV/AIDS science in 2012
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Every medical specialty has its meetings. Infectious diseases has IDSA, ICAAC and many smaller conferences devoted to narrower topics. Practitioners and scientists working with HIV and related coinfections and comorbidities are, of course, part of the broader ID community, but unsurprisingly have created their own sub-subspecialty gatherings dedicated to issues and scientific developments in the HIV domain. Two stand out.
IAS 2012
The biannual meeting of the International AIDS Society, generally referred to as the IAS Conference, is a very large gathering of interested scientists, physicians, activists, politicians, reporters and many others from across the world. The IAS Conference — being held this July in the United States for the first time since I was privileged to serve as the co-chair in 1990 — provides a sounding board for important new science, but often against a backdrop of policy and community engagement.
CROI 2012
The second major HIV meeting, the Conference on Retroviruses and Opportunistic Infections, universally just known as CROI, is held annually and always in the United States. CROI began as a more focused scientific meeting devoted to basic and clinical investigations/translational research well before the term was popularized.
Like many things, CROI has changed with the times. After 19 years, it now addresses a broader portfolio, including considerations of policy and behavioral science, hepatitis C and other infections, not just HIV. But, CROI’s heart remains in translational research, and it is an important venue for new discoveries.
As with many scientific conferences, CROI often has a “theme” unplanned but arising from significant new findings and biased by the interests of each participant. There have been many memorable CROI moments going back to some of the first presentations of truly potent antiretroviral therapy in 1996.
This year — among many presentations — I was struck by three broad areas of research featured in plenary lectures, special symposia and oral abstracts (and, of course, hallway discussions).
These areas included progress on HIV eradication, the use of antiretroviral drugs to block transmission and prevent infection, and the explosion of new drugs and optimism for the treatment and cure of HCV infection. Other attendees may have chosen other conference content, but to me, these are of broad interest to the HIV and ID community and best illustrate translational research offering tremendous hope to individuals still struggling against the HIV and HCV epidemics.
Hope for an HIV cure was, until recently, barely imagined. That changed with the report of a single patient who remains aviremic off therapy following a marrow transplant for leukemia and with the development of newer and very potent antiretroviral drugs. At this year’s CROI, one symposium addressed host factors influencing HIV replication, another focused on elite controllers, HIV-infected patients aviremic off therapy, and one symposium was titled, “Pathways toward a cure, viral latency and reservoirs.”
Finally, an oral abstract session was directed at eradication as were many poster presentations. Successful ART reduces plasma viral load below detection limits with commercial assays, but debates continue whether low level replication continues or the virus has become limited to truly latent reservoirs.
Each possibility drives therapeutic research. If low level replication continues, “intensifying” therapy by adding new drugs may be useful, whereas latent virus may be approached by intentionally activating the HIV genome followed by antiretroviral. Both approaches were discussed at CROI with an interesting approach to the second using vorinostat (Zolinza, Merck) to activate HIV with promising but preliminary results.
PrEP trial
The interface between antiretroviral drugs and prevention of HIV transmission or acquisition has been the subject of previous Infectious Disease News coverage and editorials, but remained on center stage at CROI. We learned previously that pre-exposure prophylaxis (PrEP) of those at risk for infection could decrease that probability, but inconsistently across trials in different populations. At CROI, we heard the strikingly positive outcome of another PrEP trial, Partners in PrEP, conducted in serodiscordant heterosexuals in Africa, and more information from a trial where PrEP did not succeed.
Rather remarkably, all PrEP results seem directly associated with medication adherence. Using tenofovir (Viread, Gilead) levels as a surrogate of adherence, PrEP worked when the drug was taken, didn’t when it wasn’t detected, and yielded intermediate result in the first reported trial, iPrEx, in which adherence was between the other extremes. These results generated heated discussions, and policy implications are under active international debate. Other prevention strategies, including male circumcision and the prevention benefits of treating infected patients, were also on stage at CROI, the latter also under consideration by policy, makes a demonstration project aimed at reducing average or community viral load as a public health strategy move forward.
Hepatitis C
Finally, CROI was the scene of a rather amazing amount of new and potentially game-changing approaches to treating HCV. The fraction of patients treated with the “old” standard of interferon and ribavirin is small, reflecting the toxicity and limited potency of this combination. All of this is changing rapidly with many new drugs approved or nearing approval that will allow shorter duration oral therapy that can cure the majority of cases regardless of host demographics or viral genotype.
In three sessions and numerous posters, attendees were challenged to begin to rethink their approach to HCV care. It seems increasingly true that as the volumes of HCV infected patients —with or without HIV coinfection — seek care, the ID community will be in the front ranks of this exciting attack aimed at eliminating an entire epidemic.
CROI was, as always, full of new evidence of progress. I didn’t address many important developments, including new antiretrovirals, but promise we will be doing that in the very near future. The next major HIV conference is the massive IAS Conference this summer in Washington, D.C. — we’ll be sure to share developments there as well.
Paul A. Volberding, MD, is director of the AIDS Research Institute at the University of California San Francisco, and Co-Director of UCSF-GIVI Center for AIDS Research and is the Chief Medical Editor of Infectious Disease News. Disclosure: Dr. Volberding is an adviser to BMS and on data and safety monitoring boards for Gilead, TaiMed and the NIH.