CROI 2018 Abstract eBook

Abstract eBook

Oral Abstracts

56 THE GLOBAL BURDEN OF TUBERCULOSIS AND MODELING CONTROL STRATEGIES Nimalan Arinaminpathy , Imperial College London, London, UK There is increasing recognition of tuberculosis (TB) as a major global health problem, with the post-2015 ‘End TB’ strategy reflecting renewed ambition for TB elimination. However, maximizing the impact of current, curative tools against TB is not only about disease control: it is also about understanding the health systems through which these tools will be delivered. Mathematical models of TB transmission have been helpful in informing these strategies. In this talk I give an overview of TB burden and control; I discuss some ways in which mathematical modelling has informed TB elimination strategies. Finally, I will discuss some important obstacles in global TB control today: the basic gaps in our understanding of when and where TB transmission occurs; the problem of undiagnosed TB; and the emergence of multi-drug-resistance. 57 USING WHOLE GENOME SEQUENCING TO BETTER UNDERSTAND TB TRANSMISSION DYNAMICS Neel R. Gandhi , Emory University, Atlanta, GA, USA Significant advances in TB control are needed to achieve the global EndTB goals by 2035. The global incidence of tuberculosis (TB) will need to decline by 17% annually, but is currently declining by only 1.5% per year. Transmission of TB is the major driver the global epidemic, particularly in high burden countries. Transmission not only leads to new infections, but also undermines preventive therapy when individuals becoming reinfected after completing a course of preventive treatment. Despite its important role, insufficient emphasis has been placed on studying TB transmission and implementing transmission control measures. The advent of genotyping methods 30 years ago provided an important tool for investigating and confirming transmission; however. genotyping has primarily been utilized in high-income countries where TB incidence is low. Among molecular epidemiology studies that have been performed in high-TB incidence settings, many have suggested that transmission due to casual contact in the community may account for a substantial proportion of TB cases. Whole genome sequencing represents the next-generation of genotyping techniques and holds promise to further advance our understanding of TB transmission by providing significantly greater discrimination. This talk will review recent studies utilizing whole genome sequencing in low- and high-TB incidence settings and the advances that may be achieved with this powerful tool. 58 UNDIAGNOSED TUBERCULOSIS: PROMISE FOR PREVENTION Neil A. Martinson ,Perinatal HIV Research Unit, Soweto, South Africa Early diagnosis and initiation of treatment in patients with pulmonary TB is a cornerstone TB control and is aimed at reducing morbidity, mortality and duration of infectiousness. WHO guidelines recommend symptom screening for TB disease at all health visits which, if symptoms are present, triggers laboratory investigation, usually of sputum. This is in contrast to HIV testing; where universal testing of adolescents and adults is recommended. Risk or symptoms do not determine who is tested for HIV. The strategy of universal testing for TB irrespective of the presence of symptoms suggestive of TB has been applied to groups at extreme risk for TB. Data from several sources suggest that testing sputum of all people with liquid culture detects several fold the number of cases of TB that symptom-based TB testing would diagnose. However, evidence of improved outcomes of this strategy is limited. Several of these high risk populations, - HIV-infected pregnant women, HIV-infected adults initiating antiretrovirals, household contacts and prisoners will be presented, together with the potential benefits and other implications of universal TB testing strategies. 59 NEW DEVELOPMENTS IN THE MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS Serena Koenig , Brigham and Women’s Hospital, Boston, MA, USA Drug-resistant tuberculosis (DR-TB) is a global public health crisis. Isoniazid- resistant TB (INH-R TB), which is resistant to isoniazid but sensitive to rifampin, is the most common form of drug-resistant TB in the world, with an estimated 1.5 million cases occurring annually. In spite of the high burden of INH-R TB, there are very limited data from clinical trials to guide treatment, and current guidelines are based largely on observational studies, systematic reviews,

meta-analyses, and expert opinion. Multi-drug resistant TB (MDR-TB), which is resistant to both isoniazid and rifampin, causes about 490,000 cases annually; of these, an estimated 6.2% are extensively drug-resistant (XDR-TB), with additional resistance to both fluoroquinolones and second-line injectable medications. Standard treatment for MDR-TB is lengthy (minimum of 18 months) and associated with a high rate of adverse events. However, there have recently been major advances in the treatment of MDR-TB, with the implementation of shorter regimens and new and repurposed drugs. This talk will review rapid testing for DR-TB, and the evidence base to guide treatment, including new drug regimens and data from ongoing and planned trials, with a particular focus on INH-R TB, MDR-TB, and XDR-TB. CDC estimates that approximately 1.2 million people in the United States are living with HIV. Southern states is the home to 38% of the US population yet is where 45% of people living with HIV reside and where 50% of new infections are occurring. Nationally it is estimated that 85% of people living with HIV know their serostatus but in 10 out of 17 Southern states, this percentage is lower. Similarly, the percent who know their status is lower for persons younger than 34 years-old. Despite evolving the new HIV epidemic in the US is very much like the old HIV epidemic with the great majority of new infections happening among gay and bisexual men, however black men who have sex with men (MSM) and Hispanic/Latino MSM account for the largest number of new HIV diagnosis. There are also important racial disparities in HIV with Black/African Americans comprising 12% of the population yet accounting for 44% of new HIV diagnoses. The number of new HIV infections declined 18% between 2008 and 2014 but this decline has been uneven across geographic regions and populations. HIV care continuum outcomes, particularly retention and viral suppression, are key in decreasing HIV transmission. Thus, it is not surprising that the impact of treatment on transmission has not been as significant in the South and among Black/African Americans where continuous retention and viral suppression has been less than optimal. The US is far from reaching the UNAIDS 909090 goals; approximately 85% of people living with HIV diagnosed, 36% are receiving ART and 30% are virally suppressed. It is thus a public health priority to develop and implement interventions to improve retention and viral suppression to decrease regional and racial disparities in HIV and to achieve the goals of the National HIV/AIDS Strategy for 2020. Hyman Scott , San Francisco Department of Public Health, San Francisco, CA, USA HIV testing serves as the entry into the HIV treatment and prevention cascade. However, HIV testing uptake and implementation has been challenged in fragmented healthcare systems with structural, social, and individual factors (such as access, cost, and stigma) being significant barriers. New HIV testing technologies and implementation strategies have been used with varying success to address these challenges, especially with un- and under-tested populations, such as youth and black men who have sex with men. Reaching these populations is essential to increasing awareness of HIV status, and decreasing late diagnoses. Home HIV self-testing is a new technology approved by the US Food and Drug Administration in 2012, and can be effective at reaching never testers and infrequent testers among at-risk populations. In addition, partner services for those recently diagnosed with HIV or a sexually transmitted infection, and couple-based testing have the ability to reach individuals through their sexual partners. Increasing HIV testing in healthcare settings includes strategies to routinize HIV testing through opt-out testing, standing orders in urgent and emergency care settings, and passive reminders in primary care settings. The expansion of Electronic Health Records can facilitate identification of patients who have either never tested or have delayed testing, but implementation remains challenging. Linkage to HIV prevention or care services is essential after HIV testing, and often requires linking individuals to multilevel navigation support for linkage to be successful. New “status neutral” strategies tailored to support HIV testing and linkage to treatment and prevention for the most vulnerable populations in the US are needed to improve outcomes and reduce treatment and prevention disparities.

60 THE EVOLVING HIV EPIDEMIC IN THE UNITED STATES Carlos del Rio , Emory University, Atlanta, GA, USA

Oral Abstracts

61 HIV TESTING AND LINKAGE: THE GATEWAY TO TREATMENT AND PREVENTION

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CROI 2018