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Challenges Remain in HIV Care: Public Health Watch Report

As the International AIDS Society’s (IAS) 9th Conference on HIV Science wraps up this week in Paris, recent news regarding treatment of the troubling disease suggests that, in spite of significant accomplishments, challenges remain—particularly given the cloudy future of healthcare, and funding for it, in the United States.

On July 24, 2017, both Contagion® and The Telegraph reported that a 9-year-old, formerly HIV-positive South African child has “surprised experts” by achieving what has come to be called “long-term remission” following a long period of antiretroviral therapy (ART) discontinuation. Experts were quick to emphasize that the case, while suggesting that HIV treatment may not necessarily be a lifetime consideration, is still rare within the context of the hundreds of ongoing studies involving the disease and its management.

Meanwhile, preliminary findings from the REALITY trial, published in the issue of The New England Journal of Medicine (NEJM) published on July 20, 2017, found potential clinical value for “enhanced antimicrobial prophylaxis” with continuous trimethoprim/sulfamethoxazole plus isoniazid/pyridoxine, fluconazole, azithromycin, and albendazole over standard prophylaxis (trimethoprim/sulfamethoxazole alone) in the treatment of post-ART infection (typically, tuberculosis and/or Cryptococcus), a common challenge in sub-Saharan Africa, where the trial is ongoing.

After randomizing 1,805 patients (some of whom were asymptomatic or mildly symptomatic for HIV), the authors found that, at 24 weeks following ART initiation, the rate of death with enhanced prophylaxis was lower than that with standard prophylaxis (8.9% vs. 12.2%), although these figures increased to 11.0% and 14.4%, respectively by 48 weeks. Notably, patients in the enhanced-prophylaxis group had significantly lower rates of tuberculosis, cryptococcal infection, and/or oral or esophageal candidiasis; however, they found no significant differences between the 2 groups regarding the rate of severe bacterial infection.

As promising as these findings are, though, a related commentary, published in the same issue of NEJM, noted that “the decrease in HIV-associated deaths appears to have plateaued in recent years…A worrisome new trend that has been observed in countries with long-standing HIV treatment programs is an increase in the number of patients who present for care with advanced HIV infection after a period of treatment interruption.”

This latter point is particularly troubling in light of reports suggesting that an executive order signed by President Trump in January, which reinstated the “Mexico City rule,” may have deleterious effects on nongovernmental organizations working in places like Africa, where treatment compliance is already an issue. Aid workers have told The Guardian and other outlets that the restrictions spelled out in the executive order may result in interrupted and/or discontinued services for patients in the developing world with diseases such as HIV. And, as Contagion® has reported previously, advocates here in the United States have expressed concern about the future of patients with the disease under the proposed new healthcare legislation.

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