As noted previously by Carlos del Rio in his nice summary , the Conference on Retroviruses and Opportunistic Infections (CROI) turned 20 this year. It also made it’s first-ever stop in Atlanta, home of many things that begin with “C” — CDC (note that insiders rarely say, “the CDC”), CNN, Coca Cola, and Carlos himself.
I’ll spare you the boring saga of just how messed up the travel was back to the Northeast as the conference came to a close — ugh — and jump right in on this Really Rapid Review™, loosely organized by prevention, treatment, and complications.
In the VOICE study of pre-exposure prophylaxis (PrEP), none of the interventions worked – not oral TDF, oral TDF/FTC, or vaginal TDF gel. The adherence was dismal — it seems that only around 25-30% of the more than 5000 African women took their assigned treatment. At the conference, the “joke” was that at least the side effects were minimal – hey aren’t we a funny bunch of HIV researchers. The unfunny part was the alarmingly high HIV incidence among the participants, especially the young women in South Africa.
No excess in HIV incidence or high risk behavior after stopping PrEP in the iPrEx study. Quick aside — do you like it when the study title is declarative about the result, as in these two papers? I do.
In a CDC-sponsored study of 10 sentinel sites in the USA from 2007-2010, the prevalence of transmitted drug resistance among newly diagnosed patients was 16%.Breakdown by drug class: NNRTI 8.1%, NRTI 6.7, and PI 4.5%. Compared with their prior report, the overall rate is around the same, while NNRTI resistance is rising. Given the improvement in virologic suppression rates that happened in the late 2000s, I expected transmitted drug resistance to drop — maybe next time!
If a patient has failed treatment using the three original drug classes (NRTI, NNRTI, PI), and has more than two active drugs besides NRTIs on resistance/tropism testing, do you need to include NRTIs in the salvage regimen? According to this ambitious clinical trial, the answer is no. Virologic responses were similar, with or without the NRTIs. Oddly, there were six deaths in the NRTI arm, zero in the “no nukes” arm — hard to see that as being related to anything but chance, as the causes of death did not seem drug-related, but it’s weird nonetheless.
After a first-line failure of a standard two NRTIs + NNRTI regimen, lopinavir/r + NRTIs and lopinavir + raltegravir were similar in efficacy. One might expect the latter to be better (two new fully active drugs, after all), but most likely adherence was the key determinant of outcome in both study arms. This was a poster too, by the way — winner of second place in that above-mentioned award.
Cenicriviroc is a CCR5 inhibitor that also blocks CCR2 — and hence may have anti-inflammatory properties; it was compared with EFV in this phase II study. There were more virologic failures in the cenicriviroc arm, more discontinuations for adverse events in the EFV arm, but the study was small and the formulation highly problematic. Hard to know where this is going — is cenicriviroc potentially a replacement for “key third drug”, or will it be coformulated with 3TC and replace one of the NRTIs? Or will drug development stop, since it’s not as if there’s a driving need for another CCR5 antagonist? We’ll see.
In the COAT study of timing of ART initiation in cryptococcal meningitis, the early ART group had significantly shorter survival , prompting early termination of the study. Those with the lowest CSF WBC and impaired mental status did particularly poorly with early ART. A truly important study, done in Africa but with global implications.
Apologies if I’ve left out your favorite, would love to hear what I missed — and I reserve the right to add a few based on your suggestions. As for the conference venue, the meeting rooms were comfortable, audiovisuals reliable, the posters easy to see, and there were plenty of Coca Cola products available during the breaks.
Last but not least, I don’t think anyone announced where or when CROI 2014 will take place. Let the speculation begin!