CROI 2020 Abstract eBook

Abstract eBook

Oral Abstracts

successful implementation of infant vaccination program over the last decades using a combined vaccine (pentavalent: DTP-hepB-Hib) at 6-10-14 weeks of life effectively prevented horizontal transmission of HBV but not MTCT; this may lead to a change in HBV epidemiology with an increase in the relative contribution of MTCT among new infections. In order to prevent MTCT, the WHO recommends that, in addition to at least two doses of infant vaccine, all neonates should receive the first dose of monovalent hepatitis B vaccine as soon as possible after birth, preferably within 24 hours (birth dose vaccine: HepB-BD). However, this strategy is not well implemented, particularly in sub-Saharan Africa, because many African countries have not yet integrated HepB-BD in the national immunization program. Moreover, even the countries that started HepB-BD face logistical challenges for its timely administration due to high frequency of child birth outside health facilities. Recently, there is accumulating evidence, particularly from Asia, suggesting the efficacy and safety of peripartum antiviral prophylaxis using nucleos(t)ide analogues in pregnant women with high HBV DNA levels, in addition to neonatal immunoprophylaxis with HepB-BD and hepatitis B immune globulin (HBIG). This additional strategy, combined with high HepB-BD coverage, may certainly accelerate the elimination of HBV MTCT, if these evidence-based interventions are carefully tailored to women living in low- and middle-income countries where the access to HBV DNA test or HBIG is still severely limited. HSV-1 and 2 infections are common across the globe with recent prevalence estimates of 3709 million cases of HSV-1 (including 140 million cases of genital HSV-1 infection) and 417 million cases of HSV-2 infection. Women are at higher risk and acquire HSV-2 at a younger age than men. Prevalent HSV-2 increases risk of HIV acquisition 2-3 fold. An estimated 14,000 infants contract neonatal HSV infection each year, a frequently fatal disease. The risk of transmission to the newborn is highest if a woman acquires genital herpes toward the end of pregnancy. Current standard of care is to treat women with recurrent genital herpes with suppressive antivirals toward the end of pregnancy; although this approach may reduce cesarean sections, it has had no effect on the incidence of neonatal herpes. The risk of neonatal herpes in infants born to women with established infection is very low. Implementation of control strategies is hampered by lack of evidence-based interventions. Patient management is limited by lack of commercial accurate serologic assays; only partial effectiveness of antiviral for HSV in reducing the risk for sexual transmission, and persistent stigma associated with this infection. While resistance to currently available therapies occurs almost exclusively among immunocompromised patients, alternative therapies for such patients are inadequate and no new drugs have been developed for several decades. A number of vaccines are in development, mostly aimed at therapeutic use. Lack of knowledge about immune correlates of protection complicates the evaluation of candidate vaccine products. However, elimination of HSV infections is likely to be achieved only through prophylactic immunization. Valerie Delpech , Public Health England, London, UK For the third year running, reports of new HIV diagnoses among men and women fell dramatically in the England largely driven by a decline in new diagnoses among gay, bisexual and other men who have sex with men (GBM) residing in London. A CD4 back-calculation model indicates that transmission among GBM has fallen since 2012 – from 2,800 new infections (95% credible interval (CrI) 2,600 to 3,000) that year, to 800 (CrI 500 to 1,400) in 2018 (a 71% drop). Over this period the estimated number of GBM with undiagnosed infection more than halved to 3,600 – with an overall prevalence of 88 per 1,000. In contrast the prevalence of HIV among men and women who acquired HIV heterosexually is overall low (1.1 per 1,000) and greater among black Africans (36 per 1,000). Furthermore, in 2018 about two-thirds of heterosexuals diagnosed were born abroad and half probably acquired HIV abroad. Overall an estimated 3,200 heterosexuals were unaware of their infection in 2018, the majority were women. The fall in transmission is a success story of combination prevention in the making. Universal and free access to testing and treatment to all citizens is at the core of this success, together with a dedicated HIV sector. Targeted prevention and testing began early in the response. Substantial increases in testing across all groups occurred in the past decade. HIV tests by GBM at STI

clinics increased from 61,000 to 165,000 and a doubling of repeat testers to over 40,000. Treatment guidelines have recommended the early initiation of treatment since 2015. By 2018, >80% of people newly diagnosed begin treatment within 3 months (regardless of gender or sexuality) compared to 53% in 2014. The proportion reaches 90% in certain high throughput clinics in London. Test and Treat strategies have led to the exceedance of the UNAIDS 90:90:90 target across all populations (these were 93:97:97 in 2018). Scaling up of PrEP is relatively recent with informal use since 2015. By 2018 over 15,000 GBM were receiving PrEP through an STI clinic across England - with demand outstripping supply (uptake among other higher-risk persons remains very low). The expected introduction of a large-scale national PrEP programme is likely to accelerate the decline in HIV incidence provided test and treat strategies are sustained at high levels for all communities. HIV was first documented in Rakai, Uganda in the early 1980s. For over 30 years, the Rakai Health Sciences Program (RHSP) tracked the epidemic, and in 1994, established the Rakai Community Cohort Study (RCCS) among 10,000-20,000 residents ages 15-49 residing in agrarian/trading communities. In 2011, hyper-endemic fishing communities were added. A trial of sexually transmitted infection control for HIV prevention (1994-1999), nested in the RCCS, did not reduce HIV incidence. However, secondary data analyses showed that higher viral load (VL), early and late stages of HIV infection, and uncircumcised men were key drivers of the epidemic. The protective effect of safe male circumcision (SMC) was later confirmed in three trials, one of which was nested in the RCCS. Reduction of VL with ART became the basis for treatment-as-prevention. Since 2004, with PEPFAR/CDC-Uganda support, RHSP has scaled-up combination HIV interventions (CHI). RHSP now leads implementation in 12 districts, overseeing 161 clinics with over 110,000 persons on ART and over 250,000 circumcisions to-date. Recently, we evaluated trends in SMC and ART coverage, VL suppression, sexual behaviors, and HIV incidence and prevalence in 30 agrarian/ trading and four fishing communities. In agrarian/trading communities, HIV prevalence was 15.9% in 1994 and incidence was 1.5/100 person-years. Between 2004-2016, ART coverage rose from 0% to 69%; VL suppression rose to 75%; SMC coverage increased from 15% to 59%. Except for delayed sexual debut among adolescents (15-19), we did not observe other changes in sexual behaviors. Between 2004 and 2016, HIV incidence declined by 42% (1.17 to 0.66/ 100 person-years) while prevalence remained relatively stable. In fishing communities, ART coverage increased from 16% to 82%; VL suppression rose from 34% to 80% and SMC increased from 35% to 65% between 2011 and 2016. HIV incidence declined by 48% (3.43 to 1.59/100 person-years). Despite these reductions, HIV incidence remains above epidemic control rates. Ongoing epidemiological/phylogenetic studies in the RCCS suggest that in-migration and hard-to-reach persons contribute to ongoing transmissions. In conclusion, CHI reduced HIV incidence, but challenges remain. The RCCS has proved invaluable for discovery, intervention testing, and evaluation of real-world impact on HIV incidence. By combining research with intervention delivery, each informing the other, RHSP been able to translate science into population-level impact. Leandro A. Mena , University of Mississippi Medical Center, Jackson, MS, USA The South’s disproportionate burden of HIV and health care disparities is driven in part by many socioeconomic, cultural and structural factors. This talk will describe challenges to HIV prevention and care especially in the rural South as well as promising strategies aiming to promote equitable access to HIV services throughout the region. Concerted efforts and significant investments in HIV prevention and care resulted in a 69% decline in mortality and a 48% reduction in new diagnoses in the US since the mid-1990s. However, despite over $20B of Federal funding in domestic HIV efforts, new diagnoses have stabilized at about 38,000 for nearly a decade, down only 7.0% from 2012. The US epidemic is not a national epidemic but rather a collection of microepidemics disproportionately affecting racial/ ethnic and sexual minorities with 43% of new diagnoses among Blacks, 69% attributed to male-to-male sexual contact and 52% occurring in the Southern

59 30-PLUS YEARS OF HIV IN RAKAI: THE EPIDEMIC RECEDES Joseph Kagaayi , Rakai Health Sciences Program, Kalisizo, Uganda

Oral Abstracts

57 BEYOND THE STIGMA: A SORELY NEEDED PERSPECTIVE ON HSV Anna Wald , University of Washington, Seattle, WA, USA

58 REFLECTIONS ON THE UK EPIDEMIC

60 BATTLING HIV IN THE US RURAL SOUTH

61 HOW DO WE STOP THE BAND FROM PLAYING ON IN THE US? Carlos Del Rio , Emory University, Atlanta, GA, USA

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CROI 2020