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.
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.
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.
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.
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.
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.
REACH was a collaborative research and practice initiative to develop evidence building frameworks, capacity, tools and resources with the Victorian HIV community partnership.
Early first sexual intercourse has been proposed as an important marker of later sexual and reproductive health. Discussions of what constitutes early sexual debut in this context, however, have been limited.