Body & Soul Research update, 25 October 2016

Updates from BHIVA conference on . . .

• Cure – breakthrough or not?

• Long acting retrovirals – what do they offer?

• When to start treatment – asap post diagnosis?

Media reports of HIV cure “breakthrough?”

• Sunday Times 2 October: “brink of an HIV cure” • HIV undetectable in blood of “first” man to have completed trial • One of 50 (only 39 recruited to date)

• BUT don’t hold your breath . . .

What do we mean by an HIV cure?

•  Sterilising Cure •  INFECTIOUS DISEASE MODEL – the Berlin patient

•  Aviraemia; no transmission; no replication competent virus; no detectable HIV-

infected cells

•  ‘Functional’ Cure ie remission •  “CANCER” MODEL

•  • No disease progression • No CD4 cell loss

• No transmission • But...no agreed duration

What is latent HIV?

• HIV infects CD4+ cells – some become resting memory cells or reservoirs

• Major reservoirs: • Dormant memory Tcells in lymph nodes and blood • Macrophages and dendritic cells (other types of immune

system cells) in lymph nodes, the gut and central nervous system

If size matters....the hypothesis towards remission

• The longer people live with untreated HIV the larger the pool of latently infected cells

• If ART is started immediately around the time of diagnosis will it be possible to push the reservoir below a threshold, enabling viral control off therapy (treatment)?

Where we are now

•  We don’t understand the pathological consequences (potential harm) •  We are starting to understand the role of ART (but without control

groups can not be sure)

•  There is an interplay between host immunity and random reactivation

•  We are starting to develop predictors, but need more to understand the mechanism

•  Important Virological remission is real

•  We must put all of this in the setting of excellent ART and outcomes to balance risk vs benefits

What happens if people treated early stop therapy?

• What happens if people treated early in PHI stop therapy? • VISCONTI study identified 14 individuals treated in Acute

infection for average 3.5 years who stopped ART and controlled viraemia for years after stopping • They did not share the same “protective” HLA alleles • Virus could be grown in vitro from blood samples • Did they control because their level of viral reservoir was

below a certain threshold?

RIVER TRIAL is in early stages

• Research in Viral Eradication of HIV Reservoirs (RIVER) • CHERUB collaboration: five universities, NIHR funding • People infected within last six months • Fewer HIV infected cells in the body • Theory: easier to completely remove HIV & stop ARVs

How does it work?

• “Kick and kill” strategy using 4 drug combination ARV • Raltegravir used because fast acting • 22 weeks standard ARVs, then 4 drug ARV alone OR • + Vaccination to improve immune responses + Vorinostat • Vorinostat “activates” cells infected with HIV •  (10 rounds in 28 days) • HIV cells can be spotted by immune system/ARV

treatment

When will we know if it works?

• Tests will continue for “next five years” • NOT yet recommending stopping ARTs • RIVER first study results 2018: are all traces of HIV DNA gone? • BUT real test will be stopping ARTs • “Berlin patient” – bone marrow transplant – only “cure” so far recognised • Wait and see …

RIVER research – to sum up what we know

• We don’t understand pathological (potentially harmful) consequences • We are beginning to understand the role of ART – but we ethically can not have comparison control groups • Virological remission is real so we are keen to explore ….. BUT

•  It is important to put this into the context of excellent ART when considering risk vs benefits

Long acting treatment with retrovirals

• Research from Professor Saye Khoo • University of Liverpool

Long acting retrovirals

• Why long-acting ? • Potency, delivery, pharmacology • Long-acting Antiretrovirals for Treatment • rilpivirine cabotegravir other agents • PreP • Real-life challenges

Why “long acting?”

•  Improve adherence, convenience (work, travel, etc) •  ‘Fragile’ populations • Psychological benefit, pill fatigue etc •  Improves bioavailability • PK ‘smoothing’, reduced variability • Eliminates food effects and gut-based DDIs, improve GI

tolerability • Public health benefits – community VLs, transmissions

Long acting Antiretrovirals

• Monthly injections v daily dosage • How to control the daily drug delivery? • Who is this suitable for? • What drugs have been trialed? • What other issues are there?

Real-life challenges

Injection issues: needle fatigue consistency of injections - children, low BMI, gender-based differences Pharmaceutical: formulations? •  variability – BMI, gender, pharmacogenetic,

scalability, affordability implementation and health system capacity

Real life challenges - contd

• Patient problems: lead-in, lead-out, bridging scenarios/Missed dosing/Managing DDIs • New Clinical Events: eg pregnancy, contraception, - epilepsy, TB, liver/renal failure, cardiac event, cancer, surgery etc

• PreP: is there a prevention target? stopping PreP?

Long-Acting Antiretrovirals - Summary

• Potential for treatment and prevention • Generally high acceptance in research • But who for? adherence, co-morbidities? • Real-life challenges? more data on women needed • DDIs cannot necessarily be imputed from oral dosing studies

Testing and treatment of HIV within 24 hours

• Is it viable?

• Dr Nneka Nwokolo 56 Dean Street, Chelsea and Westminster Hospital

2015 statistics show massive progress in UK

• 88,000 people in the UK accessed treatment • 84,800 are on treatment • 79,800 are virally suppressed

How has this happened?

• Newer ARVs from existing classes with better tolerability • Newer ARV classes • Better evidence base (START,TasP and“Cure” • studies) • Better accessibility (generics) • Life expectancy approaching normal

Standards today are …

• New HIV diagnosis timeline is as follows: • Baseline tests, then appointment within 2 weeks: • VL, CD4, resistance test, Human Leukocyte Antigen (HLA); hepatitis screens, haematology and biochemistry; vaccination status; STI screening • Adjustment period • Start treatment according to baseline bloods and guidelines

Are patients ready to start? Should they?

• “I’m ready to start today” or “Is it safe?” • “I don’t want to be infectious” or “What about resistance?” • “I want modern once a day treatment” • “I want to preserve my immune system” •  ”Will this lead to cure?”

• Are patients being pressurised?

What research is there about treatment on diagnosis – immediate starting of ARVs?

•  Haiti study

• “Real world” San Francisco RAPID programme •

• “Real world” 56 Dean Street experience

Dean Street experience

• • All patients seen in medical appointment within 2 weeks • • All patients offered ART at 1st appointment • 26 (23%) did not start at 1st visit • - 18 declined immediate treatment • - (6 lost to follow-up; no info on 2) • Data on 87 (77%)

Positive results at Dean Street

• High acceptability of immediate testing • Fast viral load suppression • • 85% VL <200 at 16 weeks • 99% VL <200 at 24 weeks (1 individual with • High retention at 24 weeks • Success!

Challenges to same day ART initiation

• Service capacity • Acceptability to clinicians • Acceptability to patients • Infrastructure – pharmacy capacity, health adviser support

Summary

• International guidelines recommend treatment for all individuals with HIV • Early treatment particularly valuable in limiting reservoir in acute infection and preventing transmission • In some settings early treatment associated with significant improvements in linkage to care

Conclusions from Dean Street research

• Starting ART at diagnosis is challenging but feasible • Acceptable to patients • Parallel rather than serial interventions • Retention in care in UK is excellent, early treatment may reinforce this

Still to be considered – final thoughts

• Much more research needed into test and treat within 24 hours • Age profile? Women? Heterosexual? • Dean Street is MSM, urban user group • Ethics? What do you think?