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Treatment as prevention in an Australian Setting

Treatment as prevention in an Australian Setting

Current Australian HIV treatment guidelines allow initiation of combination anti-retroviral therapy (cART) at CD4 counts <500 or symptomatic HIV. Based on the HPTN052 study, many advocate initiating cART at diagnosis; how this would translate into an Australian setting is unclear. We studied a prospective cohort of cART-naïve HIV-infected individuals at Alfred Health enrolled 2004-2010 and analysed cART initiation, HIV-related illnesses and probable HIV transmissions.

We studied 79 individuals (82% MSM); 67 eventually commenced cART (follow-up 517 patients-years pre-cART and 269 patient years post-cART ). The median CD4 count for commencing cART was 309 (range 100-831), with 47 (70%) commencing cART with CD4 <350. Twelve subjects developed HIV-related illnesses; 2 of these occurred at a CD4 count >500. Thirteen developed a significant adverse reaction to cART, three were severe. We are aware of 6 probable transmissions of HIV from our cohort, all occurred prior to cART. Two transmissions occurred in subjects who had never had a CD4 count <500, whilst 3 transmissions occurred in medicare-ineligible subjects. The estimated additional drug cost of initiating cART in all subjects at HIV diagnosis was $7.8 million.

cART is frequently initiated late and is associated with HIV-related illnesses and transmissions. Initiation of cART at diagnosis (“test and treat”) in these 79 subjects may have prevented 2 subjects developing HIV-related illnesses and prevented a minimum of 2 HIV transmissions. If the entire cohort initiated cART at a CD4 count of 500 (current guidelines) this may have prevented 10 HIV-related illnesses and prevented a minimum of 4 HIV transmissions. The primary problem in managing HIV lies with slow initiation of cART in patients who are either already eligible for cART (CD4 <500) or who are medicare ineligible, both in terms of individual benefit and prevention of transmission.

Speakers: Dr Ivan Stratov
Conference: ASHM 2013
Areas of Interest / Categories: Australian Society for HIV 2013

Australian Society for HIV 2013

Delayed HIV diagnoses among gay and bisexual men in Australia

The majority of HIV diagnoses including delayed diagnoses in Australia occur among men who report homosexual contact – hereafter called gay and bisexual men (GBM). Delayed diagnosis is strongly associated with increased HIV-related mortality and morbidity. People who are unaware of their HIV-positive status may also be unwittingly transmitting HIV. We assessed trends in delayed HIV diagnoses among GBM in Australia.

Complex case report that illustrates the paucity of data for long term management of Visceral Leishmania-HIV co-infection.

HIV-associated leishmaniasis, endemic in the Mediterranean basin is a growing problem in India, Brazil and East Africa. Despite surviving for than 20 years, the clinical course of our visceral-leishmania (VL)-HIV co-infected patient illustrates several management challenges including diagnosis, speciation and drug resistance; monitoring burden of disease; access to and use of VL-treatments; end-organ toxicity and the combined immunosuppressive effects of HIV-VL.

Clinical factors associated with suboptimal adherence to antiretroviral therapy in Asia

Adherence to combination antiretroviral therapy (cART ) plays an important role on treatment outcomes. The TREAT Asia Studies to Evaluate Resistance – Monitoring Cohort Study (TASER-M) collects patients’ adherence based on a Visual Analogue Scale. The aim of this analysis was to assess the rates of, and factors associated with, suboptimal adherence in the first 24 months of initial cART in Asian patients.

Reinvigorating evidence for action and capacity in community HIV programs (REACH Project)

REACH was a collaborative research and practice initiative to develop evidence building frameworks, capacity, tools and resources with the Victorian HIV community partnership.

The impact of immune activation on natural killer cells in the setting of HIV infection

HIV disease is associated with chronic inflammation and activation of the innate immune system. This state, as measured using plasma markers of inflammation, persists following suppression of HIV viremia using antiretroviral therapy, and may increase risk of non-AIDS co-morbidities. The causes of innate immune activation in the setting of virological suppression are unclear. Natural killer (NK) cells are innate immune cells that kill virus-infected and transformed cells without prior sensitization. We have shown that NK cells are activated both phenotypically (elevated expression of HLA-DR) and functionally (increased spontaneous degranulation measured by CD107a surface expression) in virologically suppressed (VS) HIV+ individuals. NK cells also lose expression of CD16, the receptor which mediates antibody-dependent cellular cytotoxicity.

Men who take more risks avoid HIV testing due to structural barriers

Regular HIV testing is recommended in men who take sexual risks. We assessed the relationship between perceived barriers to HIV testing, and frequency of testing among men who engaged in unprotected anal intercourse with casual partners (UAIC), to inform HIV testing strategies.

Behavioural trends among Australian gay men pose increasing challenges for HIV prevention: findings from the Gay Community Periodic Surveys, 2003-1

Gay men remain the primary population affected by HIV in Australia. While recent attention has been focused on increasing HIV testing and the use of antiretroviral-based prevention to reduce infections, it is equally important to sustain safe sex and other risk reduction practices. Increases in unprotected anal intercourse (UAI), for example, may counteract any beneficial changes in testing and treatment.