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European AIDS Conference Features Latest HIV & Hepatitis C Data, New Guidelines

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The European AIDS Conference, the biennial meeting of the European AIDS Clinical Society (EACS), opened Wednesday in Brussels, the site of the organization's first meeting 25 years ago. The conference included the latest news on antiretroviral therapy (ART) for HIV, hepatitis C treatment for HIV/HCV coinfected people, and biomedical HIV prevention, as well as the launch of updated European treatment guidelines.

The opening day of the conference featured satellite sessions on microbicides and other advances in biomedical HIV prevention and an expert debate about whether a cure for HIV is feasible.

A focus of this year's meeting is the HIV and associated hepatitis C and tuberculosis epidemics in Eastern Europe and the Russian Federation, which are largely driven by injection drug use.

Criminalization and stigma against people with HIV, as well as Russia's law against "propaganda of non-traditional sexual relations," make it harder for people to get tested and into care and hamper efforts to control the spread of the epidemic, EACS officials and advocates emphasized.

"We are concerned that these provisions not only affect basic human rights, but also result in harmful public health policy since they add to the already-existing barriers related to HIV prevention, diagnosis, access, and retention in care," the organization said in a statement released Wednesday. "The legal framework in states should do everything to reduce stigmatization."

Political leaders may pay little attention to such a statement, EACS president and conference co-chair Manuel Battegay acknowledged, but "as scientists we have a moral obligation to say what is unacceptable and what is counterproductive...to be silent is to be complicit."

Belgian Prime Minister Elio di Rupo struck a similar note at the conference's opening session Wednesday evening, stating, "We must do everything in our power to fight discrimination" against people with HIV and against lesbian, gay, bisexual, and transgender people.

Kevin De Cock from the Centers for Disease Control and Prevention (CDC) was scheduled to give an overview of the history and future of the HIV epidemic in Africa, but was unable to travel due to the U.S. federal government shutdown. In a speech delivered in his stead by Peter Reiss from the University of Amsterdam, De Cock discussed the progress to date and challenges that remain in getting more people on antiretroviral treatment.

Though hesitant to speak about an "end to AIDS" in Africa, De Cock said we can reduce the number of children born with HIV, lower HIV incidence among adults, and ensure that people living with HIV do not experience disease progression and AIDS-related death.

"Africa has endured this plague with resilience and dignity and has emerged stronger," he said. "Science must drive policy and programs. Progress will be measured by equity, including for marginalized populations such as sex workers and men who have sex with men."

"I side with the optimists because all pessimism offers is the dry satisfaction of having been right," he concluded. "African stories are long, and this one may still be unfinished when we are gone."

Michel Kazatchkine, the UN Secretary-General’s Special Envoy on HIV in Central and Eastern Europe, described a "quadruple epidemic" of HIV, viral hepatitis, TB, and drug abuse. He said the number of people with HIV in the region has grown by an estimated 140% in the decade -- the only region where the HIV/AIDS epidemic continues to grow.

Only about one-third of people eligible for ART under the old World Health Organization guidelines are receiving it, with an even larger unmet need according to the new WHO threshold of 500 cells/mm3. Access to harm reduction measures such as needle exchange and opiate substitution therapy is even harder to come by in some countries, he noted.

But together, he said, models indicate that needle exchange, opiate substitution, and expanded antiretroviral treatment could reduce HIV incidence by nearly two-thirds among people who inject drugs, even if each intervention alone is only marginally effective.

The following days of the conference featured plenary session discussing the coming revolution in treatment for hepatitis C and the growing emphasis on management of inflammation and cardiovascular disease as the HIV positive population ages.

On Friday -- following a 25th anniversary gala Thursday night -- EACS released the 7th edition of its guidelines for HIV treatment and management of comorbidities including hepatitis C and TB.

The new guidelines strike a balance between individual choice and public health, giving priority to consultation between patients and their clinicians. EACS did not follow the U.S. federal guidelines in recommending antiretroviral therapy for everyone diagnosed with HIV, but rather retained 350 cells/mm3 as a floor for initiating treatment, with an expanded list of groups that may benefit from starting therapy earlier.

Treatment of people with HIV/HCV coinfection remains complex. Some people will be able to wait for forthcoming better hepatitis C drugs -- and perhaps for interferon-free combinations -- but others with advanced liver disease may not be able to afford to wait. "It's a balance between liver disease status and adverse event potential and what will happen in each country regarding regulation," Jürgen Rockstroh from the University of Bonn said at a press conference discussing the guidelines. He added that coinfection is one of the reasons to start ART early, as "preventing loss of CD4 cells reduces risk of liver disease progression."

10/18/13