But many pockets of good news remain

The 24th International AIDS Conference (known as AIDS 2022) took place July 29–August 2 in Montreal and virtually, with several pre-conferences focusing on various special topics. As usual, the international conference brought some good and not-so-good news. Go to aids2022.org for tons of reports and photos.

Preventing STIs—the DoxyPEP study

“The DoxyPEP study found that taking 200 mg of doxycycline within 72 hours of condomless sex significantly reduces the risk of gonorrhea, chlamydia, and syphilis among men who have sex with men [MSM] and trans women,” IAS reported in a press statement. “Among those randomized to take doxycycline, 65% fewer were diagnosed with an STI each quarter than those not taking doxycycline.” 

IAS called doxycycline “a game-changing tool to prevent sexually transmitted infections.”

Amen to that.

More than 550 individuals in San Francisco and Seattle were in the study. All had a history of condomless sex with a male partner within the previous year. They had also had gonorrhea, early syphilis, or chlamydia within the previous year.

Two-thirds were given doxy-cycline PEP (post-exposure prophylaxis) to use following any condomless sex. The other third continued with the current standard of care. This control arm was stopped early when the PEP regimen showed efficacy. All study participants were then given doxycycline for PEP.

The 65% reduction amounted to an STI rate of 10.7% for the doxy folks vs. 31.9% for the non-doxy takers. So that’s one person picking up an STI vs. one person plus two friends doing so.

Doxycycline is already provided for STI prevention at clinics around the country. Thank medical providers and community advocates. Thank you. Gracias. Merci!

The DoxyPEP trial was conducted at the HIV clinic at Zuckerberg San Francisco General Hospital and the San Francisco City Clinic, both part of the San Francisco Department of Public Health, and the Madison Clinic and the Sexual Health Clinic at Harborview Medical Center, both at the University of Washington. The study was funded by NIAID (the National Institute of Allergy and Infectious Diseases). Participants were either living with HIV or taking PrEP (pre-exposure prophylaxis) to prevent HIV. 

Doxy may become some people’s new best friend.

TAF shown superior to TDF for hepatitis B

For people living with both HIV and hepatitis B virus (HBV), there’s an antiviral medication that treats both viruses and should be used in co-infection: tenofovir. 

Tenofovir, however, is available in two forms. The ALLIANCE study is the first to compare the two medications in HIV/HBV co-infection. ALLIANCE found one version of tenofovir to be superior to the other for efficacy against hepatitis B.

“HIV/hepatitis B co-infection is a major global public health threat that increases morbidity and mortality beyond either infection alone,” said Dr. Anchalee Avihingsanon, of the HIV-NAT (the HIV Netherlands Australia Thailand Research Collaboration) and the Thai Red Cross AIDS Research Center. 

Although international treatment guidelines recommend a tenofovir-based HIV regimen for this co-infection, Dr. Avihingsanon said at a press conference, it is unknown which tenofovir drug is more effective against hepatitis B. “This is very important to me as a physician in Thailand,” she said.

There were 243 participants without prior treatment history, from 11 different locations. Eighty-eight percent were Asian.

In Phase 3 results out to 48 weeks, tenofovir alafenamide (TAF) showed superiority for the treatment of hepatitis B. There was a 63% suppression of hepatitis B virus with TAF vs. a 43% suppression with tenofovir disoproxil fumarate (TDF). There was also superiority in HBV antigen seroconversion of 23% with TAF vs. 11% with TDF. The study is continuing to 96 weeks. 

“The study is really exciting,” said press conference moderator and IAS president Sharon Lewin, an infectious disease physician and director of the Peter Doherty Institute for Infection and Immunity, in Melbourne. “These findings have implications beyond HIV/HBV co-infection, but also for the many people living with hepatitis B alone.”  

As Positively Aware hepatitis editor Andrew Reynolds reported in the hepatitis drug guide (July+August), hepatitis B is the most common infectious disease in the world. “In the United States, an estimated 850,000 to 2.2 million people live with HBV; about 10% of people living with HIV in the U.S. also have HBV,” Reynolds wrote. “In recent years there have been increases in HBV cases among people who inject drugs (PWID) and in mother-to-child (known as vertical) transmission in the U.S., directly related to the opioid crisis.” 

TDF is sold under the brand name Viread. TAF for HBV comes under the brand name Vemlidy. Both medications are part of several single-tablet regimens for the treatment of HIV. ALLIANCE compared Biktarvy, which contains TAF, to a regimen of dolutegravir (brand name Tivicay) plus emtricitabine/TDF (brand name Truvada). Taking two pills instead of one Biktarvy may have given the TAF regimen an edge.

Both combo medications were equally effective against HIV, with more than 90% suppression of viral load. 

Happy birthday to PrEP, but not happy equity

A research team including the CDC (Centers for Disease Control and Prevention) reported that, “PrEP was approved for HIV prevention in the U.S. in 2012; uptake has been slow. Black and Hispanic people have higher rates of new HIV diagnoses than White non-Hispanic people in the U.S.” The researchers advanced the idea of equity vs. equality for PrEP use. 

Prevention programs should be guided by PrEP equity (use relative to epidemic impact), not PrEP equality (equal use in groups, regardless of HIV diagnosis proportion),” they reported. 

Looking at pharmacy records for the first 10 years of PrEP, race/ethnicity data were found for 34% of PrEP users. The team made the assumption that the racial distribution was the same for the prescriptions without race information. They reported that the need for PrEP increased among all racial groups in all census areas examined for the decade. 

The research group also came up with a PrEP-to-Need Ratio (PnR) as a measure for equity. They described the PrEP-to-Need Ratio as “the number of PrEP users in a group divided by the number of new diagnoses in that group in the same year.” 

By this measure, they reported, “In all regions, PnR was highest for White and lowest for Black people.” The South had the lowest PnR rates of all regions. The racial and ethnic gaps only increased over time.

“Better programs are needed to provide PrEP to people at greatest risk for HIV infection,” the researchers noted in their conclusion. 

Botswana achieves 95-95-95 goal

UNAIDS (the Joint United Nations Program on HIV/AIDS) has set the goal of 95-95-95: 95% of a country’s populace knows their HIV status; 95% of the persons diagnosed with HIV go on antiviral treatment; and 95% of the people on HIV treatment achieve undetectable viral load. 

Botswana reported having not only achieved these targets, but has become one of the few countries in the world to surpass them. The country, where one in five individuals is living with HIV, offers test-and-treat programs which immediately offers treatment to anyone diagnosed with HIV. Moreover, HIV treatment is free. 

“In 2002, Botswana was the first African country to offer free HIV treatment to citizens,” the country’s Ministry of Health and Wellness reported. “Since then, Botswana has expanded treatment coverage and adopted evidence-based practices, including test-and-start and dolutegravir treatment.”

The findings come from a population-based survey that involved visiting thousands of households to offer HIV and viral load testing. This was the country’s fifth Botswana HIV/AIDS Impact Survey (BAIS V, 2021).

Although women as a group and the country’s population overall achieved 95-95-95, men only achieved the second two. They did, however, achieve more than 90% testing. 

“Gaps remain in awareness among men 25–44 years and younger adults, particularly young women,” the report noted. Nevertheless, “Botswana has made tremendous progress in 20 years and is well-positioned to end the AIDS epidemic by 2030.”

Botswana shows the value of applying evidence-based practices.

...the need for PrEP increased among all racial groups in all census areas examined for the decade.

UNAIDS report: Progress against HIV has reversed

For each international conference, UNAIDS reports on global progress in defeating HIV, or lack thereof. This year’s report, in a time of COVID, showed reverses.

 “New data from UNAIDS on the global HIV response reveals that during the last two years of COVID-19 and other global crises, progress against the HIV pandemic has faltered, resources have shrunk, and millions of lives are at risk as a result,” the agency reported. 

There was a drop in new transmissions of 3.6% between 2020 and 2021, the smallest decline seen since 2016. There were increases in new transmissions seen in Eastern Europe and central Asia, the Middle East and North Africa, and in Latin America. There were, however, “notable” declines in new HIV transmissions in western and central Africa and in the Caribbean. Still, UNAIDS noted, “even in these regions, the HIV response is threatened by a tightening resource crunch.”

“These data show the global AIDS response in severe danger,” said UNAIDS executive director Winnie Byanyima. “If we are not making rapid progress then we are losing ground, as the pandemic thrives amidst COVID-19, mass displacement, and other crises. Let us remember the millions of preventable deaths we are trying to stop.” 

Instead, “Faltering progress meant approximately 1.5 million new infections occurred last year—over 1 million more than the global targets.”

There was an increased number of transmissions worldwide in women and girls: “The gendered HIV impact, particularly for young African women and girls, occurred amidst disruption of key HIV treatment and prevention services, millions of girls out of school due to pandemics, and spikes in teenage pregnancies and gender-based violence. In sub-Saharan Africa, adolescent girls and young women are three times as likely to acquire HIV as adolescent boys and young men,” UNAIDS reported.  

Other groups greatly affected by the HIV epidemic had even greater rates of transmissions: “As of 2021, UNAIDS key populations data show MSM [men who have sex with men] have 28 times the risk of acquiring HIV compared to people of the same age and gender identity while people who inject drugs have 35 times the risk, sex workers 30 times the risk, and transgender women 14 times the risk.

“Racial inequalities are also exacerbating HIV risks,” UNAIDS continued. “In the United Kingdom and United States of America, declines in new HIV diagnoses have been greater among white populations than among black people. In countries such as Australia, Canada, and the United States, HIV acquisition rates are higher in indigenous communities than in non-indigenous communities.”

The number of people going on antiviral treatment slowed down during the year, and UNAIDS reported that three-quarters of all people living with HIV have access to therapy, but 10 million do not, and only about half (52%) of children living with HIV have access. Worse, that gap between adults and children is growing.

“These figures are about political will. Do we care about empowering and protecting our girls? Do we want to stop AIDS deaths among children? Do we put saving lives ahead of criminalization?” asked Ms. Byanyima. “We can end AIDS by 2030 as promised. But what it takes is courage.”

Read the 400-page report, entitled In Danger: The UNAIDS Global AIDS Update 2022, at unaids.org.  

UNAIDS launches new podcast

Apropos of IAS 2022, UNAIDS kicked off a new podcast, “Against the Odds.” “This is a series of frank conversations with guests whose lives have been touched in many different ways by HIV. We find out about the challenges they’ve faced, and what inspires them to strive for what may seem impossible goals,” UNAIDS announced. Go to unaids.org/en/podcasts or wherever you get your podcasts.