New research was presented at IAS 2023, the 12th International AIDS Society Conference on HIV Science, from July 23-26. The features below highlight some of the studies that emerged from the conference.
Australia on Track to Reach UN’s 95-95-95 Targets By 2025
Following news that Inner Sydney, Australia, reduced new HIV infections by 88%, research from IAS 2023 showed that Australia is also likely to reach the UN’s 95-95-95 targets for HIV by 2025. Skye McGregor, PhD, and colleagues assessed trends in epidemiological metrics from 2004-2021, calculating annual estimates for the HIV cascade and the number of new HIV infections annually. They estimated that 29,460 people (range, 25,230-34,070) were living with HIV in Australia at the end of 2021. The country achieved all 90-90-90 targets in 2020, with 91.1% of people with HIV diagnosed, 91.6% of those diagnosed receiving treatment, and 97.8% of those on treatment achieving viral suppression—the last of the 95-95-95 targets—at the end of 2021. Dr. McGregor reported decreases in each gap of the cascade and noted that the number of people living and diagnosed with HIV is stabilizing. However, the percentage of patients diagnosed and on treatment has plateaued below 92% since 2015, following a large decline in the number untreated during 2011-2014. Changes in the cascade gaps aligned with a slow uptick in HIV notifications during 2004-2014, followed by a slow decrease to 2019 and then a rapid decline. Comparable trends were observed for estimates of new HIV infections. Further, most metrics substantially improved since 2004, including after the emergence of COVID-19 in 2020. The incidence prevalence ratio fell below the UNAIDS global target of 0.03 in 2019. “As Australia stays on course to become one of the first countries to virtually eliminate HIV, the science produced here has the potential to inform the global HIV response,” an IAS chair said in a statement.” PW
More Frequent HCV Testing Warranted in Gay & Bisexual Men With STIs
Despite a reduction in hepatitis C (HCV) infection incidence among gay and bisexual men (GBM) with HIV, and low rates of HCV among GBM on PrEP, ongoing HCV testing and treatment is necessary to maintain progress toward HCV eradication. Brendan Harney, a PhD student, also noted that the behaviors associated with STI acquisition are similar to the behaviors associated with HCV acquisition. Harney and colleagues examined the association between STIs and HCV from 2016 to 2020 among 6,529 GBM with HIV. In this group, the researchers reported that 92 participants had incident HCV infections associated with syphilis (adjusted HR [aHR], 1.99; 95% CI, 1.11-3.56). Among 13,061 GBM prescribed PrEP, the researchers reported 48 incident HCV infections associated with rectal chlamydia (aHR, 2.73; 95% CI, 1.40-5.30) and rectal gonorrhea (aHR, 2.58; 95% CI, 1.30-5.13). The findings “suggest that an STI diagnosis should prompt a conversation about HCV testing, and that more frequent HCV testing may be justified among GBM with STIs,” according to Harney and colleagues.
Stimulant Use Among Patients on Long-Term Opioid Therapy
Despite a high prevalence of chronic pain, treatment with opioids, and substance abuse among people with HIV, there is little clarity about the impact of an optimal response to stimulant use among people prescribed long-term opioid therapy (LTOT) for chronic, non-cancer pain. Starley Shade, PhD, and colleagues examined whether a urine drug test (UDT) positive for stimulants was associated with opioid-related harm or discontinuation of LTOT among patients with public insurance, matching 300 with HIV on LTOT to 300 without HIV on LTOT based on age, race/ ethnicity, and sex; participants were followed from January to June 2019. In that time, 1,562 of 6,471 UDTs (24%) were positive for stimulants; however, 30 participants had 39% of the stimulantpositive UDTs. Dr. Shade and colleagues reported no statistically significant association between stimulant-positive UDTs and opioid-related ED visits or death within 90 days when accounting for repeat ED visits, with no difference based on HIV status. Stimulant-positive UDTs were associated with discontinuation of LTOT within 90 days (OR, 1.95; 95% CI, 1.68-2.27) and was more likely among Latin individuals (OR, 1.97; 95% CI, 1.08-3.60), and less likely among people with HIV (OR, 0.59; 95% CI, 0.44-0.79). While the association between stimulant-positive UDTs and opioid-related harm occurred among a minority of individuals on LTOT, stimulant-positive UDTs often resulted in LTOT discontinuation, and it is unclear whether less LTOT discontinuation among people with HIV who use stimulants is indicative of a more holistic approach among HIV clinicians, issues with opioid stewardship, or both, the researchers noted. Dr. Shade and colleagues suggested that instances of stimulant use should promote discussions about substance use and risk, rather than a reflex reaction to discontinue LTOT.
Stigma Leads to Inattentive, Potentially Neglectful Treatment
Healthcare stigma has a complex, significant impact on the physical and mental health of MSM, but most studies assess healthcare stigma based on self-reported measures that may be affected by bias. Ye Zhang, PhD, presented results from a study that used trained, standardized patient actors to assess the impact of stigma on healthcare quality. They conducted 123 visits with 41 healthcare professionals at 17 clinics. Dr. Zhang reported lower scores for clinical guideline adherence in all stigmatized scenarios compared with the reference condition of an HIV-negative heterosexual man, although only the estimate for HIV-negative MSM was statistically significant. Appropriate diagnostic testing was less likely when standardized patients presented as HIVpositive, regardless of sexual orientation (HIV+straight: OR, 0.35; 95% CI, 0.00-3.35; HIV+MSM: OR, 0.08; 95% CI, 0.01-0.77). However, the researchers reported no differences in patient-centered care scores, no adverse events, and no “overtly hostile” behaviors from clinicians. The findings suggest that “stigma most often manifests in the form of less attentive or even neglectful care,” Dr. Zhang and colleagues wrote.
REPRIEVE Trial Results Exceed Expectations
HIV-related cardiovascular disease remains a prominent comorbidity among patients with HIV. The REPRIEVE trial examined the use of a statin versus placebo for preventing major adverse cardiovascular events (MACE) in patients with HIV. Findings presented by Steven K. Grinspoon, MD, showed that, in a trial of over 7,000 patients, there was a 35% decrease versus placebo in time to first primary MACE and a 21% decrease versus placebo in time to first MACE or death. The effect remained consistent in subgroup analyses, and no treatment modifications due to HIV-related variables were required. The benefit derived from the statin “exceeded anticipated efficacy,” according to the IAS, which anticipates changes to the 2019 American College of Cardiology/American Heart Association statin therapy guidelines based on the REPRIEVE trial results.
