CROI 2017: A View from My Seat at the Table
April 24, 2017
The annual Conference on Retroviruses and Opportunistic Infections (CROI) is an annual gathering where advocates and researchers learn where the science on HIV is taking us. The findings can be both grand and granular. They answer questions, raise new ones or both. And not all of those questions are strictly about science. Two of AVAC's partners have been reflecting on what they took away from the conference, insights that inform our thinking long after the sessions end and results are published.
Rob Newells is an Associate Minister at the Imani Community Church in Oakland, California, and serves as Executive Director for AIDS Project of the East Bay -- a community-based organization serving the most vulnerable and marginalized communities in Alameda County since 1983. He was a 2011 Fellow of the Black AIDS Institute's African American HIV University Community Mobilization College and has been a biomedical HIV prevention research advocate with AVAC's US PxROAR group since 2012.
There are conferences that I attend where I can be "Rob Newells, executive director for AIDS Project of the East Bay (APEB)." The Conference on Retroviruses and Opportunistic Infections, more commonly known as CROI, is not one of those conferences. At CROI, the "executive director hat" comes off, and I'm purely a community advocate again. This year, that was even more true than in previous years. As I looked around the room of Community Educator Scholars (a program that supports advocates attending CROI) as we gathered for our first early morning breakfast of the week, I immediately noticed that I was the only African American man at the table. There were two African American women (one Scholar and one member of the Community Liaison Subcommittee) and several Africans (shout out to my brothers Ntando, Simon and Supercharger), but no other Black men from the United States. It wasn't the first time that I've been the only one, and I know it won't be the last, but -- if I'm being honest -- I was both disappointed and stressed by it. I felt a lot of pressure to be the eyes and ears for my community in a way that I hadn't felt in previous years.
From a community perspective, CROI is the most boring meeting I attend. It's 4,000 science and research geeks talking to each other about what they've been doing locked away in their labs for the last few years. Most of the news that gets reported after CROI is for science and research geeks, and those reports usually miss the things that I find interesting or that I think my community would find interesting, useful, and relevant. So, in an attempt to rectify that shortcoming, I attended all of the plenary sessions and a bunch of the oral abstract sessions and even took my time to talk to presenters during the poster sessions. I took lots of notes and pictures of slides, and when I returned home (after another conference the following week) I talked it all through with my staff. It took a while longer for me to organize my thoughts into a coherent presentation that I could use for the community report-back I coordinated at the Alameda County Public Health Department on National Women and Girls' HIV/AIDS Awareness Day. This is some of what I shared.
CDC's oral presentation on HIV Incidence, Prevalence and Undiagnosed Infection in Men Who Have Sex with Men gave us good news and bad news. The good news is that the percentage of undiagnosed HIV infections decreased for all racial/ethnic groups between 2008 and 2014. (That tells me we've been doing a better job of testing.) The bad news is that there was an increase in HIV incidence among Latino MSM and MSM between the ages of 25 and 34. (Annual infections among Black MSM dropped from 10,100 in 2008 to 10,000 in 2014. I don't see that as anything to write home about, but a decrease is a decrease, right?)
I had my third or fourth high-resolution anoscopy (HRA) just before CROI, so I was particularly interested in a few of the abstracts related to anal cancer. (There were seven posters and four oral abstract presentations on anal cancer this year, so I wasn't the only one interested.) While anal cancer is fairly rare overall, men living with HIV who have sex with men are 60-190 times more likely to get anal cancer than the general population. We know that certain types of HPV are responsible for most anal cancers, and most MSM living with HIV have HPV of one type or another. What we didn't know was what we should be doing about it. What I took away from CROI 2017 was that anal cancer screening should start at 30 to 35 years old for MSM living with HIV. Insured folks like me should get an annual HRA. Unfortunately, HRA is not the most cost-effective prevention tool, and resources to perform the test are limited worldwide. Additionally, patients who rely on the Ryan White AIDS Program or Medicare for coverage have to settle for a digital rectal exam (exams where the doctor inserts a gloved, lubricated finger into the anus to feel for unusual lumps or growths) to detect anal cancer because an HRA isn't covered. As fun as a digital rectal exam may sound, it's not that effective. HRA detects the most cancers. (I know from personal experience. I asked my primary care physician to refer me for an anal pap smear and HRA a few years ago. He didn't find anything suspicious with the digital rectal exam, but he gave me the referral anyway. The HRA found a stage 4 pre-cancerous lesion which was removed during the procedure. Thank you, Kaiser Permanente.)
Bridge HIV in San Francisco is one of the sites for the AMP (antibody mediated prevention) Study, and I know people in my community who are enrolled so I paid attention. Antibodies are a big deal in HIV research. My takeaway from CROI was that the current study won't produce a home run that will work for everyone. Researchers hope to have an understanding about whether or not antibodies can work for prevention, but as public health intervention it is cumbersome, involving monthly clinic visits and transfusions. And no matter the results from AMP, vaccines based on neutralizing antibodies are still a long way off.
There were two things I found interesting in the cure research presented this year. The first was that people on effective antiretroviral therapy are not producing new HIV-infected cells. Cells proliferate before they die off. That means that earlier detection and treatment results in fewer proliferating cells with less diversity and smaller reservoirs. That might make HIV easier to target and cure. The other thing that caught my attention was that estrogen blocks RNA replication. That discovery leads to at least two pathways to cure: Can we block estrogen to bring latent cells out of hiding (the "flush and kill" strategy), or can we increase estrogen to keep RNA blocked (the anti-proliferation model)?
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