HIV and ID Observations

With CROI 2011 now officially over, I offer below the following Really Rapid Review™ for ID/HIV Specialists with limited time — or for those who said they went to the conference but spent the entire week shopping in the Prudential Mall and eating at Legal Seafood:

1. Lots on PrEP.  Bottom line — it works if you take it, but lots of people in iPrEx didn’t take it, especially in non-US sites.  And bone density goes down a bit in those receiving TDF/FTC, long-term implications not known.  Based on conversations I had with colleagues, it didn’t seem that anyone had been prescribing PrEP much thus far.
2. HCV treatment is about to get much more effective, and much more complicated.  The drug-drug interactions with antiretroviral drugs and the first two HCV-protease inhibitors — telaprevir and boceprevir — are going to be really, really dicey. Sensational web-cast here of a plenary given by Stefan Zeuzem that summarizes lots of the key issues.
3. Once-daily raltegravir doesn’t work quite as well as twice-daily. Old news, but detailed data on the trial presented here for the first time.  Turns out PK does matter after all in the QD group.
4. Speaking of raltegravir, if you predicted that approximately 25% of treatment-naive subjects who were put on boosted darunavir plus raltegravir would experience virologic failure, you are smarted than I am. These are two of our best drugs — how can we explain this?
5. Time to learn a new drug name:  “S/GSK1349572” = “572” = “dolutegravir” = “DTG”, which really does have antiviral activity against some raltegravir-resistant viruses.
6. Two additional studies (here and here) show that blacks in the USA do worse than whites in clinical trials.  The explanation must be at least in part socioeconomic, since clearly Africans in Africa are doing just as well on ART as people in resource-rich settings. Critical to figure out why we have this disparity.
7. Many studies on inflammation and immune activation, including this incredibly counter-intuitive study of maraviroc intensification of already suppressive ART.  Results are too complex for this Really Rapid Review™, but they go something like this:  certain markers increased; others decreased; no one knows why; no one knows the clinical implications.  Which pretty much sums up this whole “inflammation and immune activation” field right now.
8. If you have active TB and advanced HIV-related immunosuppression — that is, CD4 < 50 — the time to start ART is sooner rather than later. (Similar findings in this study.)  All this makes complete sense, given what we’ve seen from earlier studies in such sick patients (A5164, CAMELIA).  Fact:  Untreated advanced AIDS is worse than IRIS.
9. Several years ago, plunked right into the middle of a slide session on clinical studies of antiretrovirals, came an out-of-nowhere basic science presentation (this might have been it) on “zinc fingers”.  So odd was its appearance that it became something of an inside joke (a very inside joke) among certain HIV clinicians.  (“Oh, he can’t tolerate ritonavir — maybe he’d do better on a zinc finger inhibitor.”)  And guess what — zinc fingers are back! And it’s actually very cool stuff.
10. Does PI-based ART in the mom lead to premature delivery?  The Europeans have been saying so for some time, and this randomized clinical trial from Botswana supports that view.  The questions remain — how clinically important?  And what are the best alternatives?
11. You know that question about whether NRTIs are needed in 2nd-line therapy (and beyond)?  Based on these two studies (here and here), it certainly seems so.  A randomized clinical trial — the so-called OPTIONS study — is ongoing to try and answer this question definitively.

Finally, unlike last year, if the CROI 2012 dates were announced, I didn’t hear them — nor did anyone else I spoke to at the conference.  Darn. That “announcement” up there is a mock-up kindly crafted by my sister, who always did help me with my art projects in grade school.

But in case the conference organizers are still looking, there’s plenty of space at the Hynes Convention Center should they want to come back to Boston.  Right now, this group is the only meeting booked for the whole month of February!