HRW is dedicated to understanding the evolving landscape for people living with HIV: from latest treatment and guideline changes to the pipeline treatments that could revolutionise HIV treatment in the future. The EACS (European AIDS Clinical Society) conference in Basel presented the perfect opportunity to learn about the latest advances and to discuss the next steps towards ending the HIV epidemic.
Richard Hutchings (Senior Research Manager) has returned from the conference and brings you the hot topics, and what to look out for in the future of HIV treatment.
This year, we set our alarm clocks early to attend the first session on Thursday morning – an engaging discussion on the aging people who are living with HIV. We heard the inspiring story of a patient representative who is living openly with HIV, but recalled the stigma and challenges of the diagnosis, and discussed her journey as she is aging with the condition.
This session set the tone for the conference – highlighting that treating HIV in 2019 has its own developing challenges as patients age and treatment options improve, but is a world away from the situation in the past where patients were struggling to gain control over the virus.
The most popular session on Thursday was focused on the data for weight gain of patients on integrase inhibitors (INIs) – currently the gold standard treatments in HIV. Not only was the room completely full, the overflow rooms were overflowing, and I had to stand at the back to hear the latest data.
Weight gain is a problem when patients move into the overweight and obese categories and is a risk factor for other comorbidities. It is now clear that TAF (tenofovir alafenamide) and INI-containing regimens are most associated with weight gain, and we’re starting to see evidence to understand why. There are two main factors – the impact of these drugs on the adipose tissue of the body, and also the ‘return to wellness’ effect – the fact that when a patient’s disease becomes well controlled, their overall health improves, and with it their appetite – and weight. The jury is still out on which factors have what influence, but histological data showing increased fibrosis in viscose fat of patients suggests that these drugs do influence the behaviour of fat cells.
This new information may have a direct impact on treatment decisions. One of the most highly regarded current regimens is Biktarvy, which contains both an integrase inhibitor and TAF – meaning that there is a cumulative effect on weight gain. In the ADVANCE study, women on an INI and TAF saw an average of 9.3 kg weight gain over 96 weeks. Although this will continue to be a highly valuable regimen, physicians may start to think more carefully about using it for some patient types.
At the end of the session, the final comment came from a Swiss physician who took to the microphone to thank the presenters and the audience, and to say that 20 years ago he would have been amazed to hear in his lifetime that the most populous session of the conference was on the topic weight gain – highlighting the huge progress in the area.
Another hot topic was the real-world data emerging for two-drug regimens (2DRs). In a session titled ‘Antiretroviral therapy: Today and in the future’ we saw abstracts presented comparing 2DR patients versus those on three drug regimens. A meta-analysis showed no difference in efficacy of 2DRs versus three drug regimens, a finding supported by a Swiss cohort study, where those switched to 2DRs had non-inferior outcomes at 48 weeks – although interestingly the rates of adverse events were also equivalent (rather than being lower for 2DRs, which may have been expected). However, the study which provoked most discussion was from a Spanish cohort, which found that those on 2DRs were more than twice as likely to experience treatment failure over three years (based on a calculated hazard ratio) vs. 3DR patients. Although there was considerable discussion about the study limitations, the most interesting comment came from a physician who noted that although the hazard ratio was significantly higher, in absolute terms, only a small proportion of both groups actually failed over the three years – questioning how clinically relevant the difference was, and to what extent this should influence prescribing decisions in the real world – an interesting note to end on. We’re expecting to see more studies of this type in the future and look forward to seeing how the discussion evolves.
One of the final sessions was on the topic of HIV prevention – where we were inspired to hear about the progress being made. As PrEP usage is expanding, and initiatives such as the ‘Fast Track’ strategy in Paris are continuing, HIV diagnoses are decreasing – having fallen by 16% in Paris between 2015 and 2018.
We look forward to seeing the HIV landscape develop more in 2020 – in next year’s AIDS conference we will likely be hearing more about the next generation of treatments – long acting regimens which are close to being added to the physician armamentarium.
By Richard Hutchings