- Category: HIV Treatment
- Published on Thursday, 03 October 2013 00:00
- Written by Liz Highleyman
Should pilgrims heading to the Hajj wear face masks to avoid catching Middle-East Respiratory Syndrome coronavirus (MERS-CoV)? Do partners of HIV positive people on effective antiretroviral therapy still need to practice safer sex? And should HIV/HCV coinfected people start hepatitis C treatment now or wait for new drugs? These were among the many topics discussed at IDWeek 2013, now underway in San Francisco.
IDWeek, which debuted last year in San Diego, is the combined annual meeting of the Infectious Diseases Society of America (IDSA), the HIV Medicine Association (HIVMA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society (PIDS).
Wednesday's opening plenary featured Ziad Memish from Alfaisal University in Riyadh and David Swerdlow from the U.S. Centers for Disease Control and Prevention (via video from Atlanta due to the federal government shutdown) speaking on infection control and preventing MERS-CoV.
To date there have been 136 cases of MERS-CoV infection, mostly in Saudi Arabia. Of these, 58 people have died, for a mortality rate of 42% -- considerably lower than it appeared at the start of the outbreak. "I'm confident mortality will continue to go down until it reaches a level similar to SARS," Memish said. There is currently no definitive treatment for MERS-CoV, but a recent monkey study found that interferon plus ribavirin -- the regimen used to treat hepatitis C -- may be effective.
MERS-CoV transmission is not fully understood. Clusters of family members and healthcare workers have occurred, the latter mostly involving nurses doing intubation. The virus has been found in bats and camels, but there is "nodirect evidence" of animal-to-human transmission. Swerdlow recommended taking standard, contact, and airborne precautions, "since we don't really know how it's transmitted."
To date, no MERS-CoV cases have been detected among the 800,000 pilgrims gathering in Jeddah and Medina this month, but active surveillance is ongoing, Memish said. He noted that the Saudi health ministry has consistently recommended that people wear face masks when attending large mass gatherings, though there's "no evidence that it actually works."
Sex and ART
On Thursday, Roy Gulick from Weill Cornell Medical College and Paul Sax from Brigham and Women’s Hospital faced off in a "Clinical Controversies" debate about whether sexual partners of HIV positive people on fully suppressive antiretroviral therapy (ART) need to continue HIV prevention strategies with their partner.
Speaking in favor, Gulick argued that having an "undetectable" blood plasma viral load does not mean there is no virus at all in the body, and in particular in semen and cervical-vaginal fluid. There have been case reports in the literature -- albeit few -- of transmission despite undetectable plasma viral load.
On the con side, Sax countered that unprotected sex "is a viable option" for serodiscordant couples in long-term monogamous relationships. The groundbreaking HPTN 052 trial found that HIV transmission within heterosexual couples was reduced by 96% when the HIV positive partner started immediate ART upon HIV diagnosis regardless of CD4 T-cell count. Several other studies and a meta-analysis have reported transmission rates at or near zero when viral load is undetectable.
However, Gulick noted, HPTN was limited to heterosexual couples. Less is known about the impact of ART on transmission among men who have sex with men, but the odds of transmission via anal sex are known to be much higher compared with vaginal sex.
In short, the jury is still out on "treatment as prevention" -- it clearly works, but does it work every time? Antiretroviral pre-exposure prophylaxis, where the HIV negative partner takes daily antiretrovirals, adds yet another wrinkle.
Treat or Wait?
Later in the day Sax joined Paul Volberding, Judith Currier, Edwin DeJesus, and Joseph Eron -- who was awarded the HIVMA Clinical Education Award at the opening plenary -- for an HIV Interactive session, in which audience members voted on and the experts discussed how to handle several challenging cases.
One such case involved how to manage HIV/HCV coinfected people. Volberding favored doing a biopsy to determine the extent of liver disease, but Currier and Eron argued that if the results are not going to change the course of clinical management, why bother?
This issue is especially relevant in light of the pending approval of the first well-tolerated second-generation direct-acting antivirals for HCV. Sax noted that recent data showed that a triple regimen of pegylated interferon, ribavirin, and sofosbuvir (formerly GS-7977) cured 85% of genotype 1 patients with a 12-week course of therapy. "There's a very good chance this regimen will be available in December," he said -- assuming a prolonged government shutdown does not interfere with FDA review.
Still to come: On Saturday afternoon Myron Cohen from the University of North Carolina at Chapel Hill will give a featured lecture entitled, "The Evolution of Antiretroviral Agents: From Survival to Prevention to Cure." There will also be a symposium on "Healthcare Reform and the Future of HIV Care."
The IDWeek 2013 program and abstracts are available onlineas well as via a mobile conference appfor iPhone or Android. See breaking news on Twitter using hashtag #IDWeek. Follow HIVandHepatitis.com coverage on our IDWeek 2013 conference page (coming soon), Facebook page, or via Twitter @HIVandHepatitis.
Z Memish. Infection Control Policy and Communication of Rapidly Developing Issues around Preventing the Middle East Respiratory Syndrome Coronavirus (MERS-COV). 2nd ID Week Conference (IDWeek 2013). San Francisco. October 2-6, 2013. Presentation 29a.
DL Swerdlow. U.S. Response to MERS-CoV. 2nd ID Week Conference (IDWeek 2013). San Francisco. October 2-6, 2013. Presentation 29b.
R Gulick. PRO: Sexual Partners of HIV-Infected People on Suppressive ART Need to Continue HIV Prevention Strategies with their Partner. 2nd ID Week Conference (IDWeek 2013). San Francisco. October 2-6, 2013. Presentation 50.
P Sax. CON: Sexual Partners of HIV-Infected People on Suppressive ART Need to Continue HIV Prevention Strategies with their Partner. 2nd ID Week Conference (IDWeek 2013). San Francisco. October 2-6, 2013. Presentation 51.