EACS Conference in Barcelona
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EACS Conference
EACS Conference in Barcelona
More than 3.500 delegates from a total – We now know that every treatment is – For the first time in global health his-
of 93 countries came to the 15th Euro- beneficial. The 90-90-90 target is – theo- tory, the world has reached a global nu-
pean AIDS Clinical Society (EACS) Con- retically – in reach in Europe. A growing merical target prior to the agreed deadli-
ference that was held in Barcelona, Oct- number of people view the use of drugs as ne: Providing ART to 15 million people by
ober 21-25. an illness – not a criminal activity. Pre-ex- 2015!
posure prophylaxis (PrEP) has been high Dr Egger also said that today WHO’s
I
n his welcoming address at the Opening on the agenda – and can help curbing and guidelines states that all infected should
Session, Prof Manuel Battegay, Presi- stopping the epidemic, Mr Bereczky sum- be treated immediately – and that those
dent of EACS, welcomed them all. He marised. that need it should receive PrEP.
thanked the sponsors, patients, lectu- He continued his talk by stating that he Loss to clinic prior to ART initiation is
rers and the community – and all attende- is gay. still a large problem in certain areas of the
es for coming. – I am privileged, but many others live world, he continued.
in areas where this is regarded as bad. – But many ”lost to follow-up” are not
A systemic problem that requires a sys- This is a systemic problem that requires a really that! 17 meta-analyses and 51 tra-
temic solution systemic solution. Europe is fragmented, cing studies shows that many of them
In the Opening Session Tamás Bereczky, he pointed out. have moved to another clinic. The morta-
communication advisor of the AIDS tre- Stigma and discrimination against gay lity in this group is decreasing.
atment group and co-chair of the Europe- people exists in health care providers in The 90-90-90 target (= 90% of all HIV
an Commission’s Civil Society Forum on Eastern Europe. positive people diagnosed, provide ART
HIV/AIDS, talked about Europe. Mr Be- – They right out refuse to treat people for 90% of those, and ensure 90 % achieve
reczky began this by calling for 10 seconds with HIV! We need your help – including undetectable HIV RNA) is substantively
of silence in order to think about those not to reach out to specialists in other areas. higher than what is currently achieved
fortunate enough to be born when there We also need to concentrate more on wo- in the cascade of HIV care in any set-
was a treatment for HIV. men – they are underrepresented in trials, ting. Measuring and reporting the casca-
– And also for those who are unfortu- Mr Bereczky finished his talk. de consistently is needed for meaningful
nate enough to live where they still don’t comparisons and translation of successful
have access to care. A huge challenge – and a huge potential interventions to different settings, Dr Eg-
After this, he pointed out that a lot has Dr Matthias Egger talked about global ger summarised.
happened since the last EACS Congress in epidemiology, and started by stating a glo- – 90-90-90 represents a huge challenge
Brussels 2013. bal target that has been achieved. – and a huge potential. You should know
HIV & VIROLOGY NEWS 1 · 2016 3
EACS Conference
your cascade – with its special and key
populations. Monitoring should be stan-
dardized by defining numerators, deno-
minators and time points. We also need to
adapt and develop monitoring systems, Dr
Egger ended his lecture.
Access to ART remains low
– If we do not reach 90-90-90, we’ve just
heard that there will be no end to AIDS.
That goes for Europe too, said Dr Michel
Kazatchkine, UN Secretary General Spe-
cial Envoy on HIV/AIDS in Eastern Euro-
pe and Central Asia.
In Eastern Europe and Central Asia the-
re is an expanding HIV epidemic, largely increased by twofold between 2004 and % of newly reported cases are diagnosed
driven by unsafe injection drug use. 2013. Rates of infection more than trip- as late presenters.
– But we also experience a heterosexu- led in Albania, Bulgaria, Czech Republic, – There is increasing evidence of
al transmission as a major component of Hungary, Montenegro, Slovakia and Tur- post-migration HIV acquisition and the-
epidemic growth. key. refore of the need for migrant-sensitive
The access to ART remains low – ove- HIV remains concentrated in key popu- services for HIV testing – combined with
rall estimated coverage is 35 %. HIV pre- lations, including men who have sex with policies that ensure access to care for this
vention is not accessible at a sufficient men (MSM). The number of cases among population.
scale, and health systems are vertical and MSM has more than quadrupled in the In his summary Dr Kazatchkine stated
provider-centred. There are high levels of last ten years. that the targets of 90-90-90 in Europe by
stigma and discrimination and low levels – A high number of people are unaware 2020 are achievable in Western and Cen-
of co-operation between governments of their status. A high proportion – more tral Europe.
and the non-governmental sector. There than 50 % – of HIV positive people are – But I think we still have a lot of work
are also issues around financial sustaina- diagnosed at late stages of the disease, he to do. We must keep up the fight – so we
bility, Dr Kazatchkine said. continued. one day can end AIDS in Europe!
– In Central Europe, there remains an
overall low prevalence of HIV. Rates of ”We still have a lot of work to do” Statins have an anti-inflammatory effect
newly diagnosed infections have however Although the number of new diagnosed In his speech at the Opening Session, Prof
HIV infections has decreased in Western Battegay presented a list of sessions at
Europe over the last ten years, there has the Congress that he personally thought
been a sustained increase in HIV diag- was of special interest. One of these was
noses in MSM – which remains the main on co-morbidities – a joint session with
transmission mode in the region. the 17th international Co-morbidities
– Interventions to improve testing, pre- Workshop. In this, Prof Turner Overton
vention and control among MSM are cor- talked about the interplay between athe-
nerstones of the HIV response and need rosclerosis and inflammation.
to be significantly strengthened – inclu- He described atherosclerosis as a dyna-
ding PrEP, Dr Kazatchkine stated. mic, maladaptive inflammatory process.
He said that he thought we really – The impact of HIV on cardiovascular
should reflect upon the fact that despite disease (CVD) is comparable to traditio-
Michel Kazatchkine Turner Overton provision of universal health care, 20 - 40 nal risk factors, including hypertension,
diabetes mellitus and hyperlipidemia,
Prof Overton established.
Controlling viral replication reduces
the CVD risk.
– But despite ART, inflammation per-
sists!
Potential interventions beyond supp-
ressive ART include smoking cessation,
key lifestyle factors such as diet and exer-
cise, ART switch and lipid lowering thera-
py, i.e. statins.
– Statins do not only lower LDL, they
also have anti-inflammatory effects, he
continued.
There are no reliable inflammatory
markers to predict CVD risk.
– Interventions to reduce inflammation
are needed to reduce morbidity and mor-
4 HIV & VIROLOGY NEWS 1 · 2016
EACS Conference
tality. We can’t stick our heads in the sand, is established. But how to operationalize – And we have to consider the proba-
Prof Overton concluded. frailty – with standard care or adapted bility that these scenarios will arise, Ms
care – is still debated, he said. Cambiano stated.
Increased risk for hypertension in HIV He presented the Frailty Index, that ob-
Dr Ken Kunisaki presented the results jectively measure the extreme vulnerabi- Many providers are unaware of PrEP
from a trial on the effects of immediate lity of the individual, and provide a mea- Epidemiologist Anastasia Pharris said
versus deferred ART treatment on lung sure of biological ageing. that momentum is growing in Europe
function decline. – The Index is based on an arithmetical with regard to the use of PrEP as a part
HIV patients have a higher risk for foundation, and presents potentialities for of a comprehensive approach to HIV pre-
chronic obstructive lung disease (COPD), cost-effective analyses and is characteri- vention among some populations.
Dr Kunisaki said. zed by a strong medical background. – But there are challenges: Many poten-
– The trial found that immediate or de- tial PrEP providers do not yet know that it
ferred ART has no impact on lung func- PrEP among MSM seems to be cost-ef- exists! Some potential providers may not
tion decline in HIV positive patients with fective be experienced with ART, sexual health
CD4 over 500 cells/mm3, he told the Another session concerned PrEP. counselling and risk assessment. Many of
audience. Research statistician Valentina Cambia- them never go to CROI...
This means that immediate ART can no presented a statistical analysis on the And in Eastern Europe the proportion
be offered without concern for increasing cost-effectiveness for PrEP for HIV pre- of gay male responders who state that no
COPD risk in these patients. vention in MSM in the UK. medical staff or health care provider is
– Other non-ART factors should be ex- To determine cost-effectiveness means aware of them being gay is 81 %.
plored regarding potential effect of HIV to determine the costs of intervention and Also some factors related to European
on COPD risk. alternative scenarios, she explained. health systems makes decisions on fun-
CVD is a growing concern in the ageing – Health outcomes are measured and ding and implementing PrEP complex.
HIV-infected population. Hypertension is valued, and costs and health outcomes are – In Europe, health provision tends to
an important risk factor for CVD, so it is compared to the reference scenario – i.e. be state-provided and financed and the
important to unravel the risk factors for usual care. decision to provide PrEP is done by public
hypertension in the context of HIV, said Substantial price reductions of ART bodies considering cost constraints, Ms
PhD student Rosan van Zoest. used for PrEP is needed to give necessa- Pharris pointed out.
She presented a study with the objec- ry assurance of cost-effectiveness and for A lot of actors in Europe have the op-
tives to assess whether the prevalence of an affordable public health programme of portunity to collectively address and do-
hypertension is higher in HIV-infected sufficient size, according to an earlier ana- cument solutions to implementation chal-
individuals than in HIV-uninfected cont- lysis that Ms Cambiano presented. lenges – at policy, care provision, provider
rols – and to identify HIV-related deter- However, in the data she presented, the and patient levels, she summarised.
minants of hypertension, in addition to use of PrEP among MSM in the UK seems
established risk factors. to be cost-effective – when PrEP is offered
– We found that HIV-infected individu- to MSM in the context of a clinical risk as-
als do have a higher prevalence of hyper- sessment.
tension, and that HIV-positive serostatus – We are presently conducting sensiti-
is independently associated with hyper- vity analyses varying PrEP effectiveness,
tension, Ms van Zoest said. HIV testing rate once PrEP becomes av-
The effect of HIV may – at least part- ailable and sexual behaviour in people
ly – be mediated by stavudine-induced li- receiving PrEP and in the general popu-
poatrophy and increased waist circumfe- lation.
rence, was the study’s second conclusion. In some of these plausible scenarios,
– It is important to raise the aware- PrEP will likely not be cost-effective, she
Ken Kunisaki Valentina Cambiano
ness of increased risk for hypertension in added.
HIV-infected individuals, and the study’s
findings reinforces the need to avoid the
use of stavudine.
Limiting the occurrence of abdominal
obesity is important in preventing hyper-
tension and reducing cardiovascular risk,
she ended her talk.
Index for frailty
Frailty was defined as ”a medical syn-
drome with multiple causes and contri-
butors that is characterized by diminished
strength, endurance, and reduced physio-
logic function that increases an individu-
als vulnerability for developing increased
dependency and/or death”, by Dr Matteo
Cesari.
– I have to say that the concept of frailty
HIV & VIROLOGY NEWS 1 · 2016 5
EACS Conference
Short-course cART in pregnancy
Another session had the title Gender is-
sues in HIV. In this, PhD student Susie
Huntington spoke about short-course
ART in pregnant women.
– There are more than 1.100 pregnan-
cies per year among HIV-positive women
in the UK. Until recently, pregnant wo-
men with a CD4-count higher than 350
cells/mm3 not yet on therapy, were re-
commended short-course cART, she said.
Ms Huntington presented a study that
aimed to assess whether the use of short-
course cART in pregnancy is associated
with inferior clinical and virological out-
comes once therapeutic ART is subse-
quently started.
The finding was that – compared to Mr Kuepper Tetzel also said the study had
ART-naive women – women with cART found that current antiretroviral drugs do
use in pregnancy were as likely to achieve not increase the risk for depression.
viral suppression and had similar increa-
ses in CD4 count. They were also more Gender an important predictor of reten-
likely to interrupt ART and to rebound tion in ART
6 - 24 months after suppression. Possible Dr Marisol Valenzuela-Lara presented
mechanisms for this could include adhe- a study about retention of people living
rence and resistance. with HIV under medical care at the Mex-
– However there are also possible con- ican Ministry of Health, and to describe
founders – such as socioeconomic status the differences between genders.
and family size. – A total of 50.813 individuals were in-
In the future short-course ART is un- cluded in the analysis, she underlined.
likely to be used in pregnancy as the UK Mortality in the first year of ART re-
moves towards universal ART, was her mains a challenge. This is probably still
first conclusion. a reflection of late diagnosis and delay in
– Around 10 % of women starting li- linkage to care and treatment, Dr Valen-
fe-long cART in the UK will have used zuela-Lara said.
short-course cART in pregnancy. Whilst Even though more and more people
we may expect slightly poorer outcome are starting ART with CD4 counts over
for these women, compared to ART-nai- 350 and 500, further efforts are needed to
ve women, the differences are small, were address this gap, she emphasized.
Ms Huntington’s last conclusions. – Gender remains an important pre-
dictor of retention in ART. The results of
Sex and gender related differences on this study show that men are more likely
depression to remain in treatment – which means
People living with HIV/AIDS (PLWHA) that women do not benefit equally from
are exposed to extraordinary mental ART, and that women continue to expe-
stress, Mr Claus Philippe Kuepper Tetzel rience significant disadvantages that re-
pointed out. sult in health disparities!
– Depression is the most common men- Barriers for treatment retention in wo-
tal illness in PLWHA with an estimated men in Mexico are similar to those around
prevalence up to 32 %. But there are few the world – for example lack of empower-
sex and gender specific recent studies on ment, economic dependence, restricted
this. We therefore initiated one, he expla- mobility and childcare responsibilities. the eight update were presented.
ined. – Women account for 47% of people – We are very aware of that clinicians
The findings indicate that it could be living with HIV in the world! In order to use them in their daily practice, so we stri-
beneficial (for depression) for a man to achieve 90-90-90 goals, it is necessary to ve to make them a useful tool – easy to use
receive ART. continue developing models of care that in a busy clinic, said Prof Jens Lundgren,
– But in women we don’t see that! take into account the specific needs of wo- Guideline Coordinator.
The study’s findings establish that dep- men living with HIV on ART, Dr Valenzu- Prof Jürgen Rockstroh underlined that
ression symptoms do show sex and gender ela-Lara summarised the EACS Guidelines 8.0 have sections on
related differences. hepatitis and co-morbidities.
– Depressive symptoms decline with EACS Guidelines – That is not found in all other guideli-
the duration of ART in men, but not in wo- One of the highlights at the EACS Con- nes, he said.
men. Changes in therapy increase the risk gress is the presentation of the new EACS Prof Rockstroh continued by pointing
for depression in women, but not in men. Guidelines. So also in Barcelona, where out that most of the changes are on HCV.
6 HIV & VIROLOGY NEWS 1 · 2016
EACS Conference
– They call for direct-acting-antiviral analysis of the EACS and WHO Guideli- and a median time between estimated in-
(DAA) therapy, and present a list of diffe- nes. fection and enrolment of 38 days presen-
rent combinations you can choose from, – They are going to the same direction ted an interesting fact:
depending on genotype. It’s a great tool, in terms of principles and key recommen- – 87 (13%) of these patients were
he stated. dations, but show differences in terms of asymptomatic!
Dr Anton Pozniak also highlighted main preferred and alternative approaches in He explained that during the first weeks
changes in ART. some areas, he said. after the infection, most will test negative-
– It’s when to start. Everyone should EACS guidelines emphasizes the the- ly.
start treatment – not just those under 350! rapeutic advances and quickly incorpora- – Therefore rapid testing and home tes-
Dr Pozniak also said that since PrEP is te proved innovative approaches in their ting is not appropriate.
recommended in the guidelines, the hope recommendations. WHO guidelines has a Dr Ghosn also said that the highest risk
is that doctors will point it out to the au- strong population and programmatic fo- for sexual transmission is during the first
thorities in their countries, and say: cus and establish strong guidance on how three weeks after seroconversion – it is
– Here are the data. How do we go for- to implement these scientific advances, then even higher than in end-stage AIDS.
ward with it? Dr Vitoria explained. Diagnosis of PHI is challenging, so we
At the Guidelines session Dr Marco Vi- – Both approaches are complementary must think and be suspicious about it, he
toria, WHO Geneva, gave a comparative and are needed to end the AIDS epidemic! concluded.
EACS Guidelines are available in print – cART initiated at the time of PHI
as a booklet, from 2015 as a free App for stops forward transmission. Also cART in-
IOS and Android systems by the Sanford itiated at the time of PHI allows achieving
guide – and online on the EACS website. levels of HIV-DNA as low as in those in
The session was ended with a panel de- post-treatment controllers. The role of in-
bate. tegrase inhibitors still need to be further
addressed in this setting.
Highest risk for sexual transmission
during the first three weeks Switch study
In a session on antiretroviral therapy Dr Study GS-US-292-0109 is the largest, ran-
Jade Ghosn talked about managing pri- domised, switch study in HIV-positive,
mary HIV infection (PHI). Findings from virologically suppressed adults conducted
Jade Ghosn Marisol Valenzuela-Lara
a French cohort of 674 patients with PHI to date
This randomized, open-label, acti-
ve-controlled study is to evaluate the
non-inferiority of switching to a tenofovir
alafenamide (TAF)-containing combina-
tion single tablet regimen (STR) relative
to maintaining tenofovir disoproxil fuma-
rate (TDF)-containing combination regi-
mens in virologically-suppressed HIV-1
positive subjects – as determined by ha-
ving HIV-1 RNA less than 50 copies/mL.
Dr Bart Rijnders presented week-48
data in virologically suppressed adults.
– In both the overall population and in,
those switching to elvitegravir, cobicistat,
emtricitabine and tenofovir alafenamide
10 mg (E/C/F/TAF) had comparable or
even better virologic success and signifi-
cant improvements in spine and hip bone
mass index and less osteopenia, Dr Rijn-
ders reported.
They also had significant differences in
serum creatinine and significant impro-
vements in proteinuria, albuminuria and
tubular proteinuria, he added.
– There were increases in total choles-
terol, LDL and HDL and unchanged total
cholesterol/HDL ratio, Dr Rijnders con-
cluded.
Maturation inhibitor
Results from second generation HIV-1
maturation inhibitor (MI) BMS-955176,
Phase IIa proof-of-concept study was pre-
sented by Dr Carey Hwang.
8 HIV & VIROLOGY NEWS 1 · 2016
EACS Conference
– BMS-955176 is a potent, once-daily,
MI. It has similar antiviral activity against
both wild-type HIV-1 with Gag polymor-
phisms not responsive to a first-genera-
tion MI. It was generally well tolerated,
with no serious adverse events or discon-
tinuations due to this, Dr Hwang told the
audience.
In his conclusion he stated that the
antiviral activity and safety results in sub-
jects with HIV-1 subtype B and C support
continued global development of BMS-
955176.
– Two Phase IIb studies are ongoing: A
dose-finding study, and a study investiga-
ting BMS-955176 as part of a booster – and
nucleot(s)ide-sparing therapy.
Migrants
The Russian Federation and Ukraine to-
gether account for over 90 % of reported
HIV cases in Eastern Europe, Dr Cristiana
Oprea said in a session on the last day of
Congress.
– Intravenous drug users (IDU:s) is the
main driver of HIV infection. In the west
MSM are the main driver, she pointed out. ticipants. People sense there is still a lot to
Access to ART in the region is lower do, Prof Battegay answered.
compared to Western countries, and the- He underlines that it had a good mixtu-
re is an increased gap between new cases re of science and a record number of ab-
and access to cART. stracts of high quality.
– The rates of viral suppression are low – There is a sense of operational science
in most of the lower and upper-middle – optimisation of treatment to individual
income countries and there is a need in levels, and that is important.
identifying the breakpoints in the cascade Prof Battegay underlined that standard
of treatment care. Scale-up of HIV treat- of care has to be put into place – utilising
ment and strengthening of national stra- Meetings and E-learning of management. Manuel Battegay José Gatell
tegies for HIV prevention – focused espe- – All this is our mission: Training and
cially on the high risk populations – are education, standard of, and access to, care – The inclusion of PrEP in the Guideli-
mandatory, Dr Oprea said. and issuing the Guidelines. nes has caused a discussion of standard
Dr Julia Del Amo talked about migrants For the first time basic science was re- of care, which I think was one of many
and access to care. presented at the EACS Congress. highlights. The situation in some parts of
– cART is not available for undocumen- – It was a tiny plant – but we expect it Europe is catastrophic – in several areas
ted migrants for many Central and Eas- to grow. it is worse than in Sub-Saharan Africa, he
tern European countries, as well as Fin- There were many highlights in Barcelo- underlines.
land, Denmark, Germany, Austria and na, and Prof Battegay mentioned the Ope- This is why EACS is as relevant as ever.
Switzerland. Are these countries aware of ning Session among many others. The next European AIDS Conference
WHO’s ”test and treat” approaches? she – It had three lecturers, who each provi- will be given in Milan, Italy, October 25 -
asked. ded different pieces of the same common 28 in 2017.
As expected, migrants from the majori- cause, he explained.
ty of origins start cART at lower CD4 cell Prof Battegay also praised Prof José Ga-
counts than the native population. tell as the local conference co-chair, who
– The good news is that the median CD4 managed to organise everything to come Per Lundblad
cell count at cART initiation has increased together. Senior writer
over time for native, as well as for migrant, Prof Gatell underlines that both co-
populations, Dr Oprea finished by stating. chairs main task is to work with the Sci-
entific Programme. (Per Lundblad is a Journalist specialising in med-
”A tiny plant expected to grow” – For Spain, the benefit of having the ical subjects and Senior writer for HIV & Virology
After the Congress, HIV & Virology News Conference is that the participation of News. He is employed by the publisher of the Ma-
gazine, Mediahuset i Goteborg AB. He has no other
spoke to EACS President Manuel Batte- Spanish researchers is going to be high,
affiliations with, or involvement in, any organiza-
gay on his impressions. he said. tion or entity with any financial interest or non-
– It was a very lively conference. I’m Prof Gatell points out that PrEP was a financial interest in the subject matter or materi-
also very impressed by the number of par- hot topic at the Conference. als discussed in his articles.)
HIV & VIROLOGY NEWS 1 · 2016 11
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