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The year ahead in HIV

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06 Jan 2015

Now we’re into the new year, it’s time to look at the hot issues and key challenges that lie ahead.

Easier drug access

From 1 July, people living with HIV will be able to access their HIV medications from community chemists.

If you live in an inner city, it’s likely that you will be able to collect your drugs on the spot with minimal hassle. However, those living in regional Australia may find collection more problematic and will more than likely have to drop off a script and pick up the meds a few days later.

It’s expected that most chemists will provide extended hours for dispensing, and maybe even open seven days a week. Others may be able to provide a free delivery service. (Be assured that HIV medications are packaged discreetly.)

Whilst gaining easier access to your HIV drugs is undoubtedly a good thing, there are some legitimate concerns — particularly around privacy, especially in small towns. If you have any worries, talk to your pharmacist.

PrEP trials

All eyes will be on the Australian PrEP trials this year. There are currently three ongoing. The largest, the PRELUDE study, is being held in NSW; in Melbourne there is the VicPrEP study; and in Queensland there is the QPrEP demonstration project. The aim is to explore the acceptability, feasibility, uptake and impact of taking Truvada as an HIV pre-exposure prophylaxis. 

Overseas studies have shown encouraging results: in trial after trial, Truvada — a single pill combining tenofovir and emtricitabine — has been found to be highly effective in reducing the risk of HIV transmission. It is expected the Australian trials will deliver similar results which will in turn, no doubt, lead to urgent calls for Truvada to be licensed for use as PrEP here.

The ‘Mississippi’ trial

Another trial set to stir interest this year is the IMPAACT study. Its aim is to better understand how administering antiretroviral treatment (ART) to HIV-infected newborns can potentially functionally cure them of the disease.

Conducted in the US at the National Institutes of Health, the trial was initiated by the so-called ‘Mississippi baby’ case. After receiving ART 30 hours after birth and remaining on treatment for the next two years, the baby appeared to be HIV-free. (Unfortunately, the virus returned to detectable levels early last year.) Even so, researchers remain excited by the results.  

Involving almost 500 babies from at least nine nations, the IMPAACT trial will see HIV newborns given ART within 48 hours of birth. After two years of treatment, the children will come off medication for as long as they retain an undetectable viral load. The hope is that some of them will stay in remission or even be ‘cured’.

Testing, testing

Conducted by GPs, peer educators and nursing staff, a rapid HIV test takes around 30 minutes (including the time you wait for the preliminary result). There are two different kinds of rapid test: one collects oral fluids; the other involves a finger prick.

Last year, more than 40 rapid testing sites operating across Australia successfully attracted people who had never tested for HIV before. In an effort to catch the estimated 7,000 cases of undiagnosed HIV, expect an expansion of locations in 2015.

2014 saw restrictions lifted on HIV home-testing kits. Already available in the US and given the go-ahead in the UK, the kits — likened to home pregnancy tests — will make HIV testing more accessible, particularly for Australians living in remote communities.  It is hoped that the first DIY kits will be made available in Australia sometime this year.

New treatments

Currently before the TGA pending an application for licensing, Triumeq is a single tablet regimen (STR) containing three medications: dolutegravir, abacavir and lamivudine. Developed by ViiV Healthcare, Triumeq has already been approved by both the US Food and Drug Administration and the EC, becoming the fourth STR available to treat HIV.

Taken daily (with or without food), each tablet contains 50 milligrams of dolutegravir, 600mg abacavir, and 300mg lamivudine. Triumeq’s most common side effects are insomnia, tiredness and headache. TGA approval and availability of Triumeq would offer people living with HIV in Australia the first STR without food requirements or restrictions.

Cobicistat (or COBI) is a new ‘booster’ drug which is expected to be approved by the Pharmaceutical Benefits Scheme later this year. It is currently being considered as a potential alternative to ritonavir in other HIV drug combinations. Much like ritonavir, COBI raises the concentrations of protease inhibitors in the blood allowing for lower doses of the PI than might otherwise be required to fully suppress HIV replication.

While similar to ritonavir in composition, COBI has a much better side-effect profile. It also has fewer HIV drug interactions than ritonavir. However, COBI has been found to adversely interact with drugs to treat erectile dysfunction such as Viagra. It may also increase levels of amphetamines including ecstasy, cocaine, speed and meth. 

Criminalisation

Responding to community advocacy, the LNP Victorian government last year announced its intention to “amend” Section 19A of the Crimes Act 1958 (the only HIV-specific law in Australia to discriminate against people living with the disease). But now that there is a new Labor Government in Victoria, it is expected — as promised pre-election — that Section 19A will be repealed altogether.

Stigma

It’s getting on close to 30 years since the Grim Reaper sent men, women and children hurtling down the bowling alley of death. Back in the day, it was understandable for people to be scared of AIDS. Little was known about the disease, aside from the fact it was a killer.

But for some time now, developments in treatment have ensured that people living with HIV are living well and living longer. Not only that, as major international studies have found — providing a positive person is on treatment and maintaining an undetectable viral load — there is almost zero risk of HIV transmission.

Yet stigma still persists. A New Zealand survey last year found that — despite being aware of how HIV is transmitted — 47% of respondents said they would be uncomfortable sharing a home with someone living with HIV; 56% said they would feel uncomfortable having food prepared for them by someone living with HIV; while 87% of people were uncomfortable having sexual contact with someone living with HIV. This fear and ignorance is echoed in study after study.

Such stigma prevents people living with HIV from disclosing their status to family, friends and sexual partners. This in turn leaves people living with HIV feeling isolated and fearful of rejection. Stigma also prevents people testing for HIV. 

It is 2015: way beyond time for attitudes to change and for the wider population to become aware of the facts about HIV. It should be regarded no differently to any other lifelong manageable condition. To coin a phrase: ENUF.    

Ending HIV

The key challenge this year is to increase efforts to realise the virtual elimination of HIV transmission by 2020. The target, outlined in the Seventh HIV National Strategy, has been endorsed by every state and territory health minister.

A crucial step towards achieving the aim is to hit the interim target of reducing sexual transmission of HIV by 50% this year. Another important target is to have 90% of people with HIV on treatment as soon as possible.

It’s imperative, therefore, that government and community sector organisations work together cooperatively and decisively to rapidly scale up and deliver testing, treatment and prevention so that these goals are met.

Australia has led the way in setting such targets — 2015 is the year in which to deliver the results.

BY CHRISTOPHER KELLY