In last week’s column I wrote about a ‘cure’ case (though it’s too early to say cure!) from CROI, a large HIV conference held in Seattle. I will summarise some of the other key findings this week.
Firstly, HIV pre-exposure prophylaxis (PrEP). The eagerly awaited results of the DISCOVER trial were presented: this trial randomly allocated HIV-negative gay men and transgender women at high risk of HIV to one of two treatments. One group got tenofovir-DF/emtricitabine, the drug licensed for PrEP, used in the IMPACT trial and the one you can buy online. The other group got tenofovir-AF/emtricitabine – a new version of the same medication that’s licensed for HIV treatment where it’s as good as the old version but with less impact on kidneys and bones.
The newer version of tenofovir reaches higher levels in some bits of the body but lower levels in others, including the rectum. So it was (for me) a surprise to see the new version worked just as well as the old! The newer version would need less kidney test monitoring but it’s unlikely to be as cheap as the older version which is now available as a generic (unbranded) version.
The old version is safe for most people and as we want people on PrEP to have an HIV test at least every 3 months, kidney tests are fairly easy to do at the same time. If we get routine access to PrEP in England we could learn a lot from New York; a sexual health clinic there presented data showing they were able to get 97% of people started on the same day as attending clinic!
The other big news was injectable HIV treatment. Smaller studies had shown us that injections of two HIV drugs were effective at controlling HIV and popular with patients (patients who chose to enter an injectable study that is).
At CROI we saw two presentations (including one from Professor Chloe Orkin, an HIV consultant in London and chair of the British HIV Association) showing injectables are as good as tablets at keeping HIV undetectable and again, people preferred injections. There were some issues; a lot of people get pain at the injection site (though it goes away by 3 days) and a few people with a particular strain of HIV got rebound of the virus with resistance, but overall the results were great!
Injectable treatment allows people to not have to think about HIV every day and could be a real benefit for people who struggle to take tablets for one reason or another. However, the reality of monthly injections, whether clinics have the capacity to deliver them and whether the NHS will routinely fund the extra work remain to be decided.
There were lots of studies on weight gain. Traditionally people with HIV tended to gain weight when they started HIV treatment because HIV has caused them to lose weight, i.e. they were returning to a healthy weight. Now that people start treatment much earlier (and increasingly within days of diagnosis) this is probably less of an issue but a number of clinics noticed people seemed to particularly gain weight with some of the newer HIV drugs.
Change in weight is a contentious issue, there is rarely a single cause but naturally people prefer to ‘blame’ their treatment than their eating or exercise habits. Although some of the results were conflicting overall there are signals that a group of drugs called ‘integrase inhibitors’, particularly one we use widely called dolutegravir, and tenofovir-AF, the new version of this drug that was studied in DISCOVER, are implicated. We’ve certainly come a long way from using the drugs that caused stigmatising fat loss, but it’s important to understand what effect drugs have, and why, so we can advise people correctly.
Finally we saw several presentations on new drugs – some in very early stages but promising nonetheless. Most people do very well indeed on current medications but there are always people who need new options and it’s reassuring to know that there are new drugs, and new ways of giving drugs, on the horizon.
The Boyz Doc is Dr Laura Waters, an HIV and sexual health consultant at the Mortimer Market Centre in central London. Dr Laura answers your questions every week in Boyz. If you have a question for Dr Laura please email her at firstname.lastname@example.org