Standing at the crossroads in HIV management: implications for primary care practice from the AIDS 2014 conference

Increase testing, increase treatment, consider prophylaxis, search for a cure and try to eradicate HIV

There has recently been renewed interest in HIV management in Australia. Studies have contributed evidence that effective HIV antiretroviral treatment (ART)1,2 and chemoprophylaxis3 prevent HIV transmission. There is a push to identify people with chronic HIV infection who have not been tested4 and to identify people during the acute phase of infection,5,6 when they are most infectious and most likely to transmit disease7 but unlikely to know they are infected.8 HIV treatment is more effective than it was previously; lower pill burdens cause fewer side effects and less toxicity and are less prone to the development of resistance. When combined with traditional HIV prevention measures, the use of antiretroviral agents as pre-exposure prophylaxis (PrEP) by HIV-negative people at high risk of HIV infection reduces transmission by about 75%. The World Health Organization recently recommended PrEP be integrated into prevention programs.9

The 20th International AIDS Conference was held in Melbourne in July, attracting about 14 000 delegates. The theme, “Stepping up the pace”, characterised the meeting's aim, which was to explore how all these resources and initiatives can be harnessed to have the greatest effect in the global control and ultimate eradication of HIV. There is rekindled interest in HIV cure research, including the continuing pursuit of a vaccine. Speaking at the opening ceremony, UNAIDS Executive Officer Michel Sidibé espoused 2020 targets of 90–90–90: 90% of people living with HIV knowing their status, 90% of people with HIV receiving ART, and 90% of people receiving ART having an undetectable viral load. The Australasian Society for HIV Medicine (ASHM) held a special session to look at Australia's past role and its new strategic directions nationally (Baggoley, TUSS04) and internationally (McDonald, TUSS04) in relation to HIV. (All proceedings cited here can be accessed by name or session number at the conference website.10) While attendees were upbeat about the potential for ending HIV, the disparity in opportunities between developed and developing countries was an ever-present reality. How does Australia stack up, and what are the challenges for primary care?

Chronicity and cure

In the developed world, HIV is now a long-term, manageable chronic condition. This is the case in Australia for people who are diagnosed and are eligible for Medicare, but the drugs remain expensive and current treatment needs to be taken for life. Cure research suggests that it might be possible to flush HIV from the system if treated early enough (TUAA01). While this remains an aim, follow-up of the Mississippi baby thought to have been cured of HIV infection found that HIV again became detectable after an extended period of no treatment.11 Nevertheless, cure researchers were excited that HIV viral replication was held at bay as long as it was, and see this as a line of investigation. However, a cure is still elusive. While vaccines may be a long way off, primary care remains the ideal setting for long-term chronic disease management and a central point for identifying HIV infection.

Control

The conference began with an overview of the tools we now have to control HIV and how a combination of treatment and prevention can have a synergistic effect in reducing infections (Abdool Karim, MOPL01). Key in demonstrating the prevention benefits of treatment are PrEP trials, which are beginning to report findings. When taken regularly, ART prevents HIV acquisition, and this protective benefit appears to be holding when condom use is not universal (TUAC01). A combination of PrEP and condom use remains recommended (Bavinton, WEAC01). Challenges and obstacles to PrEP for health care providers were explored (Wright, WESY04) and deserve continued discussion. PrEP is often misunderstood as being “a morning-after pill”, flexible or a short-term commitment, but these studies indicate the need for regular dosing to sustain drug levels sufficient to confer prevention. PrEP works, but it needs to be taken rigorously. The Centers for Disease Control and Prevention in the United States have produced comprehensive guidelines,12 and demonstration studies are currently underway in Australia.

Discussion of the role of HIV testing has become increasingly nuanced. It is not simply about laboratory performance, but also about clinical strategies that identify those living with chronic infection. These strategies include indicator-triggered testing, where the presence of diseases that are common in HIV trigger HIV testing, irrespective of other risk factors;13 normalising voluntary HIV testing, where there is no longer a requirement for detailed pretest counselling, simply a requirement for informed consent;14 making testing available in more settings;15 and simplifying the return of test results.

Simplification of treatment

HIV treatment is much simpler than it used to be. The recommended first-line ART in Australia is a once-daily regimen combining three drugs.16 This commonly results in a rapid decline in HIV viral load to an undetectable level (viral suppression) and a steady increase in CD4+ T cells, indicating restoration of a damaged immune system (Cooper, FRPL01). Monitoring viral suppression and treatment tolerance can then be done routinely in general practice, with intermittent specialist review, and many people can keep taking first-line therapy for years. This makes HIV truly a disease that should be managed as a chronic illness in primary care. Previously, treatment regimens were more prone to failure and the development of resistance. While initiation of HIV therapy is restricted to accredited prescribers, all primary care clinicians can participate in the shared care of patients living with HIV.

Complex management

Management of HIV in the older patient is something of particular interest in Australia, as many of our HIV patients have been living with HIV for decades and, as a consequence, are experiencing illnesses associated with ageing. It appears that HIV directly, or possibly indirectly through the drugs used to treat it, accelerates the ageing process (THBS01). It is hypothesised that this effect may be reduced if treatment is initiated earlier, before inflammation associated with HIV has an impact (Deleage, WEAA01). Preventing the damage caused by inflammation associated with early HIV disease is one of the key principles driving earlier treatment initiation (WEAA01). The pragmatic argument is often put that treatment is not delayed in other diseases, yet in HIV, which is clearly communicable, considerable debate has centred on when to start treatment. Historically, this has been a function of wanting to delay the toxicity and difficulties associated with treatment so as to maximise the duration of impact. However, with safer, easier treatment options, this argument holds less weight. We were reminded at the conference that long-term studies are still needed and that there is variation between guideline approaches and recommendations (Cooper, FRPL01).

Domestic and regional responses

The Australian response to HIV was described in the ASHM special session (Wright, TUSS04) and a satellite symposium held by the New South Wales Ministry of Health (SUSA30). Jurisdictional and national strategies are urging greater testing and greater treatment. Barriers to testing are being removed and access to treatment is being expanded, but many social barriers remain (Altice, FRPL02). Australia reaffirmed its commitment to a regional HIV response through supporting regional capacity development. This stands as a reminder that much of the region is experiencing a significant HIV epidemic (McDonald, TUSS04), which has implications for Australians who travel for work and recreation. Global mobility means that we are seeing a change in the characteristics of HIV presentation in Australia, and while 70% of infections are among men who have sex with men, 30% of infections are not, making the question “Could it be HIV?” all the more important. We are at a crossroads — we have the tools, we have the commitment; now we need to harness these to achieve the aim of ending HIV.