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HIV/AIDS Updates/JAMA-Aging/Treatment guidelines/PrEP/Cure/Vaccine/HCV
  from Jules: The new current JAMA issue is dedicated to many key issues related to HIV/AIDS, and is just before the Intl AIDS Conference starts in a few days in Durban, here is a review & summary - of note Aging gets a key mention & it is said we need "multi-faceted programs to address increasing needs of aging", I can tell soon 50-70% HIV+ will be over 60-65 particularly in NY, SF & LA where the epidemic started sooner...PrEP, prospects for a cure, the new IAS Treatment Guidelines & its updated recommendations for treatment, the burden on the healthcare system as we move forward to increase treatment are all key issues discussed. Bear hin mind we have a cure for HCV with 90-100% cure rates & even newer therapies here & coming within the next 2 years that will further improve cure rates, but the new budget proposes again to spend only $34 million on HCV, preventing us from eliminating the HCV epdeimic wich could be accomplished, all because The white House & Congress refuse to recognize this & undertake the necessary means, because of the stigma of HCV, if there were a cure for cancer we would eliminate cancer & The White House appoints Biden to head the search for a cancer cure costing untold billions, yet they refuse to fund eliminating HCV which could cost in total $10-20 Bill, bear in mind the federal govt spends every year $20 billion alone on HIV medicaid/medicare into perpetuity.
"Multifaceted programs will need to be developed to address the increasing needs of aging HIV-infected people.....an aging epidemic will present new challenges......all individuals who are diagnosed as having HIV infection should initiate treatment independent of CD4 cell count as soon as they are ready, and the sooner the better"
Another challenge posed by the success of treatment is that HIV-infected people are getting older. In cities with mature HIV epidemics, such as San Francisco [and NYC, LA], more than half the individuals living with HIV are older than 50 years.21 This trend will continue to increase in resource-rich environments and in more constrained environments where access to antiretroviral therapy continues to increase. Although antiretroviral therapies can curtail the development of opportunistic infections in HIV-infected individuals, some of the early inflammation and immune reservoir destruction may not be fully reversible. Thus, individuals living with HIV may be at risk of longer-term morbidities such as the development of cancers or atherosclerosis. Multifaceted programs will need to be developed to address the increasing needs of aging HIV-infected people......The current set of IAS-USA guidelines integrates treatment and prevention for the first time...........http://jama.jamanetwork.com/article.aspx?articleid=2533044 Men With HIV Age Faster According to DNA Methylation Study.....http://jama.jamanetwork.com/article.aspx?articleid=2529156
recent studies suggest that the burden of chronic immune stimulation and inflammation that accompanies early asymptomatic HIV infection can result in long-term morbidity6; thus, earlier treatment is of great benefit to individuals. Moreover, other studies such as HPTN 0527 have demonstrated that early initiation of antiretroviral therapy results in virologic suppression that makes HIV-infected people significantly less infectious to their partners. Thus, the prompt initiation of treatment has become a hallmark of a public health strategy to contain the epidemic ("treatment as prevention").......The current set of IAS-USA guidelines integrates treatment and preventionfor the first time......A successful response to the epidemic requires the recognition that social and structural drivers of the epidemic, including poverty, HIV stigma, homophobia, and punitive policies directed at people who inject drugs, may impede engagement in care......http://jama.jamanetwork.com/article.aspx?articleid=2533044
Newer data support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count.......Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities......Recommended optimal initial regimens for most patients are 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs........Daily tenofovir disoproxil fumarate/emtricitabine is recommended for use as preexposure prophylaxis to prevent HIV infection in persons at high risk. When indicated, postexposure prophylaxis should be started as soon as possible after exposure.
-- HCV/HIV - HIV-infected patients with hepatitis C virus (HCV) coinfection should start an ART regimen with drugs that do not have significant drug interactions with HCV therapies (evidence rating AIIa). The recommended regimens that have the fewest drug interactions with current HCV treatments are dolutegravir/abacavir/lamivudine and dolutegravir or raltegravir plus TAF/emtricitabine. Clinicians should consult current HCV treatment guidelines prior to using any other ART regimens, particularly those that include NNRTIs, boosted HIV PIs, or elvitegravir/c.
in HIV-infected persons, ART is effective in preventing HIV transmission1,4,5 and provides individual and public health benefits. Antiretroviral therapy for individuals at risk of acquiring HIV infection (as postexposure prophylaxis [PEP] or preexposure prophylaxis [PrEP]) prevents HIV acquisition......http://jama.jamanetwork.com/article.aspx?articleid=2533073
In this issue of JAMA, Rodger and colleagues7 report data from the PARTNER study...prospective, observational cohort of 1166 serodiscordant couples with the HIV-infected partner receiving ART and having plasma HIV RNA levels less than 200 copies/mL.....The main finding was that 11 uninfected partners became infected with HIV, 10 among MSM and 1 among the heterosexual partners. Notably, none of these infections proved to involve viruses phylogenetically linked to the HIV-infected study partner. As a result, the authors concluded that there were no transmission events from virologically suppressed HIV-infected participants to their uninfected partners.........clinicians need to be clear that even though the overall risk for HIV transmission may be small, the risk is not zero and the actual number is not known, especially for higher-risk groups such as MSM.....http://jama.jamanetwork.com/article.aspx?articleid=2533043
  The prospective, observational PARTNER (Partners of People on ART—A New Evaluation of the Risks) study.....Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy.......http://jama.jamanetwork.com/article.aspx?articleid=2533066......Among serodifferent heterosexual and MSM couples in which the HIV-positive partner was using suppressive ART and who reported condomless sex, during median follow-up of 1.3 years per couple, there were no documented cases of within-couple HIV transmission (upper 95% confidence limit, 0.30/100 couple-years of follow-up). Additional longer-term follow-up is necessary to provide more precise estimates of risk.
The power of combining treatment and prevention has resulted in the formulation by UNAIDS of the 90-90-90 strategy to be accomplished by 2020.....extending this to 2030 with a strategy of 95-95-95 is estimated to avert an additional 17.6 million HIV infections and 10.8 million AIDS-related deaths between 2016 and 2030,8 and carries the expectation that the pandemic will be eliminated (ie, the global prevalence of HIV will be reduced to a negligible amount and no longer represent a global public health threat).
enormous challenges remain in reaching these goals. They include the difficulties of engaging key populations with the treatment and prevention benefits, the fragility and weakness of the health care systems needed for their delivery, the fact that neither a vaccine nor cure is expected within this time frame and ART remains a lifelong therapy with challenges of linkage to care, medication adherence, and loss to follow-up all impinging on sustained viral suppression. Continued stigma and intractable human rights challenges, comorbidities, such as tuberculosis (the leading cause of mortality in people living with HIV/AIDS), and increasingly drug-resistant tuberculosis, all pose major hurdles.
In addition, it is unclear whether the costs to local and international communities will be bearable, estimated as increasing from the current $19 billion per year to $36 billion per year, and whether political will can be sustained over time.9 A central question at the 2016 IAS conference will be if, with the now-available powerful prevention and treatment tools, these goals and strategies are realistic and attainable or, at best, only aspirational......http://jama.jamanetwork.com/article.aspx?
VACCINE - Fauci.....Neutralizing antibodies have long been considered the "gold standard" of protection for vaccines against viruses because of the consistent observation that essentially all viral infections induce neutralizing antibodies, typically within days of infection.......Indeed, the field of HIV vaccinology is in uncharted territory. If efforts in developing an HIV vaccine based on the induction of bNAbs are successful, this achievement will represent the most elegant and complex scientific approach toward any vaccine in history. In contrast, if unsuccessful, this experience will be recorded as the most highly sophisticated and scientifically elegant proof that the development of such a vaccine is impossible. Hopefully, the former and not the latter will be true.......http://jama.jamanetwork.com/article.aspx?articleid=2533075
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