CROI 2018 Abstract eBook

Abstract eBook

Oral Abstracts

105 THE INTERSECTION OF PrEP AND SEXUALLY TRANSMITTED INFECTIONS Julia A. Schillinger , CDC, Atlanta, GA, USA Bacterial sexually transmitted infections (STI) are increasing in the United States at the same time as increases in the awareness and utilization of biomedical advances in HIV treatment (TasP) and prevention (PrEP). In this environment, rates of reported new HIV infections have stabilized, and even declined in some areas. This presentation will examine a confluence of factors which may be contributing to observed increases in bacterial STI. Trends in chlamydia, gonorrhea, syphilis, and HIV in the years before and after the availability of PrEP will be described using national and local surveillance data. On the population level, the uptake of PrEP could contribute to increasing STI rates because the regular, biannual (at least) STI screening recommended for all people on PrEP may increase detection of asymptomatic, or recent infections. However, broad increases in STI screening and detection are likely occurring independently of PrEP, due to increased availability of extragenital (anorectal and oropharyngeal) nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis, improved provider adherence to longstanding national recommendations for screening all men-who-have-sex-with-men (MSM) for these largely asymptomatic pathogens, and the ease afforded by patient self-collected specimens. Changes in sexual behavior may also be expected in the context of TasP and PrEP. Sexual risk compensation related to PrEP may play a role in increasing STI transmission among people who are, and are not on PrEP. A decreased fear of HIV infection, and knowledge of the low risk of transmission from persons with an undetectable viral load may also result in changes in sexual behaviors that increase the risk of other STI. Roel Coutinho , University Medical Center Utrecht, Utrecht, Netherlands Among persons at high risk to acquire HIV, oral PrEP has been shown to be effective, with good adherence the infection risk being reduced with 70% or more. Based on these studies PrEP is now recommended for people at substantial risk to acquire HIV. Preventing HIV among high incidence groups will potentially also have a significant impact on onward HIV transmission to sexual ( and needle sharing) partners. In most high income countries the majority of newly diagnosed HIV infections are among MSM. In some countries there is evidence of a declining incidence in this group due to earlier HIV detection and immediate ART initiation. Modelling studies show that providing PrEP to MSM at highest risk will have a significant additional impact on the HIV incidence by the combined effect of averting HIV among high risk MSM taking PrEP and the prevention of onward sexual transmission to others, estimates ranging from 15-60% reduction. A lowering impact of PrEP on the HIV incidence can also be expected among injecting drug users (IDUs). In this group PrEP should be combined with other prevention measures (needle exchange, early detection of HIV infection and immediate ART initiation) and embedded within a social and medical care program. Heterosexual migrants from high endemic countries are eligible for PrEP on an individual basis but molecular studies indicate that onward HIV transmission to others is limited so the overall impact on the HIV incidence will be low. In high endemic countries PrEP can be an additional individual tool to reduce HIV incidence in high incidence key populations like young women, sex workers and MSM. Rolling out PrEP programs in high endemic countries should be carefully balanced against and/or offered in combination with other effective interventions especially early HIV detection followed by immediate treatment. PrEP implementation requires a medical infrastructure to uninterrupted deliver PrEP with regular health checks. Investigating novel options to deliver PrEP (e.g. injectable), to circumvent problems of adherence/delivery will be beneficial. To evaluate the impact of PrEP on the HIV incidence in real world settings it is essential to set up monitoring programs to see whether those at highest risk are adequately being reached. Linda-Gail Bekker , University of Cape Town, Cape Town, South Africa We know that PrEP is protective and recommended for HIV prevention across populations, with good tolerability and very few safety risks. So what are the remaining controversies that are challenging us as we head towards PrEP scale- up? This talk will tackle five of the debates currently raging: (1) The potential impact of PrEP as a safer conception measure; (2) The time to protection at different mucosal surfaces; (3) PrEP isn’t an option in adolescent populations; (4); There isn’t sexual disinhibition with PrEP; (5) PrEP can be cost-effective 106 IMPACT OF PrEP ON HIV INCIDENCE 107 FIVE CONTROVERSIES IN PrEP SCALE UP

especially when used intermittently? Are these controversies real? Are they myths? What is the known evidence? 108 TAKING THE LEAP IN PrEP SCALE-UP: A GOOD TYPE OF CHALLENGE Nelly R. Mugo , Kenya Medical Research Institute, Nairobi, Kenya The HIV prevention field finally has a highly effective biomedical intervention in oral PrEP. There has been a purposeful effort to expedite population level PrEP delivery, with different trajectories by different countries. During this session, we shall review the various strategies that guide PrEP scale up. Walking through the journey and process taken by different countries in PrEP scale up, we will explore the characteristics of early adopters and factors that drive uptake and broad scale uptake by populations that most need it. We will discuss considerations raised by skeptics and their role in informing delivery process and the social and health benefits, beyond HIV prevention. Patricia M. Flynn , St. Jude Children’s Research Hospital, Memphis, TN, USA The World Health Organization estimates that over 4 million children have been infected with HIV, most via vertical transmission. Before effective treatment, mortality rates of 50%within the first two years of life were expected. The availability of safe and effective ART has radically changed this outcome and most children living with HIV infection who have access to ART are now thriving. However, long-term effects of HIV infection and its therapy have significant impact on aging up adolescents and young adults living with perinatal HIV infection. Most adolescents and young adults living with perinatal HIV infection in high-income countries have been exposed to sequential antiretroviral regimens, including monotherapy. Combined with adherence difficulties, many have evidence of viral resistance and cannot take advantage of once daily fixed drug combination ART. Many of the complications of long-term HIV infection seen in adults are also present in adolescents and young adults living with perinatal HIV infection, including renal and metabolic diseases and bone loss. However, the main impact of long-standing HIV infection and its treatment has been on growth and development, including neurodevelopment. Interpretation of research in this area is complicated by the identification of optimal control subjects, survivor bias, and contribution of the underlying social and economic characteristics of those at risk for perinatal HIV infection. Deficiencies in cognitive development, most notably executive function deficits, combined with normal maturational changes in adolescents affect behavior and academic success further complicating ART adherence and maturation into independent adults. Risk-taking behavior, common in normal adolescents, may also be heightened by cognitive difficulties resulting in increased risk of HIV transmission to sexual partners and unplanned pregnancies with potential for perinatal HIV transmission. In 2015, it was estimated that there were 1.8 million children less than 15 years of age living with HIV infection; 1.6 million of these children live is Sub-Saharan Africa. A better understanding of the complexities of growing up with HIV infection will help prepare low and middle-income countries of the world where ART is now available to successfully manage their aging up populations of adolescents and young adults living with perinatal HIV infection. 110 ARE WE ON THE FAST TRACK TO “BEND AND END”THE HIV EPIDEMICS? Helen A. Weiss , London School of Hygiene & Tropical Medicine, London, UK Goals of the HIV community include dramatically reducing the number of new infections and ensuring that people living with HIV have a long life of high quality, using rights-based approaches. This talk will examine global progress towards reaching ambitious aims such as reducing the number of new HIV infections from 1.8 million in 2016 to 500,000 in 2020, and 200,000 in 2030. This goal is operationalized as “90-90-90” i.e. that by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression. Immense progress has been made recently to increase uptake of HIV testing (for example through expansion of community-based and HIV self-testing kits), linkage to care (including through offering immediate ART to those newly diagnosed) and improving adherence (including through community-based and psycho- social support strategies). There are striking gaps in the uptake of testing and treatment for many groups, including the young, males and key populations, but several recent studies are using innovative strategies to improve uptake in these groups. To “bend and end” the HIV epidemic curve, greater focus is 109 GROWING UP WITH HIV

Oral Abstracts

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CROI 2018