From the London Patient to the DISCOVER trial and everything in between, HIV experts provide their biggest takeaways from CROI 2019, in the second part of our highlight reel.
We sat down with several HIV experts to learn more about their research and asked them to share what they’re taking home from CROI 2019. Here's what they said:
Interview transcript: (modified slightly for readability)
Paul Sax, MD: Well, one of the highlights of the conference was the presentation of the DISCOVER study, which compared TDF/FTC for preexposure prophylaxis to TAF/FTC for preexposure prophylaxis.
The TAF/FTC formulation has been shown to be safer from a renal and bone perspective. Encouragingly, the study showed that TAF/FTC was non-inferior to TDF/FTC for prevention in high-risk individuals. I want to emphasize that both treatment arms were extremely successful; there were very few incident HIV infections. It just shows that in the era very effective preventive efforts, new entrance to HIV prevention have a very high bar to reach.
Monica Ghandi, MD, MPH: My biggest takeaway from this CROI meeting so far has been the impact of combined treatment and prevention worldwide on how we are going to completely change the face of this epidemic if we put resources into combined treatment and prevention.
Personally, as a provider, 1 case of remission in a patient doesn't have as much impact for me as the impact of that we have the tools, we know that we can treat everyone, or prevent HIV, we know that we have PrEP — now, we may even have a different type of PrEP.
We know how to get to the end of this epidemic and demonstration projects are showing it all around the world that we can get there. This is such an exciting time to be an HIV. We have to now give it a few more resources, give it a little more time, and get to the end of the epidemic by putting treatment and prevention together and making that fully accessible worldwide.
Susan Swindells, MBBS: This CROI has been a terrific conference. It's always good to get all these people in the same building and get different perspectives from people in different fields of HIV that we don't normally work with.
Obviously, a big highlight was the report of the cure of a second patient in London — that's just always nice to see, it doesn't surprise me terribly that there was one, but it's still nice to see. Otherwise, we've got some good progress in prevention, there's a nice robust pipeline of new anti-HIV therapies, hepatitis is looking up, we had some good TB studies and so it's been a great conference I've enjoyed it.
Piertro Vernazza, MD: I wasn't so excited about things that people were jumping on like cure issue, which is not really a cure to me.
But, the repeating theme that I realize now, after being at these AIDS conferences for more than 30 years, is all the new drugs that are presented have no side-effects. Years later, we see the same drugs that are presented with side effects. From that I have learned we have to look for our old drugs that we know better, that have low side effects. I think those are important drugs and we shouldn’t really always believe that new drugs have no side effects which this is the way they are presented.
Saye Khoo, MD: Clearly, there’s a lot of excitement about the London patient. The London patient doesn't suggest that as a preferred mode of treatment, but it certainly it tells us that there is a hope for cure and I think that that is that is a very important message for people to hang on to.
Other than that, there are there are ups and downs. The down is perhaps this realization of weight gain in integrase inhibitors. And I think as I said before the realization that it's so important to do studies. It's not just there's not just a humanitarian imperative to give drugs to everybody. but an ethical imperative to make sure that drugs are safe in pregnancy when they're so widely given I think that's come to the forefront and that can only be welcomed.
Julia Marcus, PhD, MPH: I was pretty excited to see the DISCOVER study presented comparing daily oral TAF to Truvada, and that was presented this morning. In terms of themes I think there's been a theme around PrEP discontinuation and a lot of focus on what is it that helps people stay on PrEP, why do people discontinue PrEP, how long do they stand PrEP, etc.
So, I think we're focused still on PrEP uptake, but I think now we're moving toward other parts of the PrEP continuum of care. We’re thinking about not only how do we help people initiate PrEP, but how do we help them stay on PrEP, and how do we differentiate between appropriate and then appropriate discontinuation topics.
Paul Drain, MD, MPH: Already one of the hot topics is the London Patient, who may be the second HIV cure patient, which is which is quite exciting and it's really kind of re-energized the HIV cure field in a really fantastic way.
I think the other big highlight was Dr. Anthony Fauci’s presentation at the opening session on the plan to coordinate the end of HIV/AIDS, at least incident cases, in the United States. And to think that this is possible with the current administration is really a bold and ambitious plan. And, I think it really highlights that HIV/AIDS, and infectious diseases in particular, is not a bipartisan issue that people are split among. We saw that President Bush created the PEPFAR program, so I think there's a lot of momentum to really have a big impact on HIV.
Some of the other talks I'm excited to see are really around how do we improve the delivery of services that's been happening — whether it's in the United States or in resource-limited settings. I think we're finding that we need to be a little bit more nuanced and how we address patient-centered or client-centered care, and really tell the tailor services to people rather than having a one-size-fits-all system.
Lynn Mofenson, MD: Well, a lot of people said the biggest highlight was the new cure patient which I found to be very interesting, but for the purpose of the work that I do in low- and middle-income countries, not so relevant yet. But, from my point of view there were 2 reports about using integrase inhibitors in late pregnancy showing a very rapid viral decline — one was using dolutegravir, the other one was using raltegravir – and, it tells us that there is a very specific place where these drugs are extremely important, and that is in women who are presenting for the first time in the third trimester and you need to get their viral load down quickly.
Even with this concern about neural tube defects, since the neural tube closes by week 8, use of the drug in the third trimester is fine. And so I thought that was very exciting to be able to see that we can rapidly reduce viral load in these women who were at high risk of transmitting to their babies.
Melanie Nicol, PharmD, PhD: Interesting story, I got to ride the elevator with Timothy Ray Brown. I just got shuffled into the crowd with him, so that's probably most exciting thing for me.
But, from a science standpoint, I was obviously very interested in the results of the DISCOVER trial. To me that was one the biggest announcements that for at least men who sex with men TAF and TDF seemed to have equal efficacy for PrEP, although there's a lot of questions remaining. They didn't study it in women at all, there was no cis-women in the study, and less than 1%, I think of their population, were transwomen. So, it's not clear if these results translate to them.
We also don't know if it can be dosed to the same as TDF-based PrEP, we know that you can use on-demand dosing for TDF whether you can do that for TAF is still not clear. But, I think it's still very promising and exciting. Obviously, TAF is associated with less bone problems and less kidney problems so from a safety standpoint, I think a lot of clinicians have been waiting for this data.
For the first part of the highlight reel, click here.