This Week in HIV Research: One Step at a Time

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Incremental change may not be as sexy as a major, seismic shift, but its impact can be just as significant, if not more so. That's as true in research as it is in any other context, and this week's selection of recently published HIV-related journal manuscripts continues the march of slow, steady improvements across a range of issues that impact patient care.

This week's collection includes these findings:

  • An integrated stepped alcohol treatment method may yield benefits in HIV clinics.
  • Heart risk screening among people with HIV could be enhanced by assessing inflammation-affecting cytokine levels.
  • CCR5 gene editing for HIV protection may have another downside: reduced lifespan.
  • "Test and treat" for hepatitis C is generally cost effective -- except where budgets are extremely stretched, such as U.S. prisons.

Join us on a brief journey through each of these steps forward in HIV research. To beat HIV, you have to follow the science!

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Multi-Step Alcohol Use Treatment May Provide Benefit in HIV Clinics

Among people living with HIV and alcohol use disorder, integrated stepped alcohol treatment (ISAT) did not reduce the number of weekly drinks any more than the usual alcohol treatment method, according to a study of 128 people attending U.S. Veterans Affairs HIV clinics that was published in The Lancet. However, ISAT did appear to yield several benefits over treatment as usual, suggesting promise for the method, study authors suggested.

Participants were randomized to ISAT (63 people) or treatment as usual (65) for 24 weeks. Both arms then continued on standard treatment through week 52. At that point, 34 people were left in the original ISAT group] and 52 in the control group. About half of ISAT participants received alcohol treatment medications, which could be prescribed during addiction physician management in Step 1. If drinking targets were not met after four weeks, four sessions of motivational enhancement therapy were added in Step 2. A third of participants attended two or more of these sessions. After 12 weeks, those who still exceeded drinking targets were referred to specialist services in Step 3. Meanwhile, "treatment as usual" included only brief counseling and referral to specialists.

Although the number of drinks consumed by ISAT recipients each week was no lower than people receiving treatment as usual at 24 and 52 weeks, ISAT recipients did show a number of improvements, including fewer heavy drinking days, fewer drinks on days when alcohol consumption occurred, and greater likelihood of having an undetectable viral load.

Study authors called for promoting ISAT while enhancing patient engagement and retention in the program.

Moderate white blood cells inflammatory response
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Pro- and Anti-Inflammatory Cytokines May Predict Heart Risk in PLWH

In people living with HIV, screening practices for cardiovascular disease risk may need to go beyond analyzing traditional risk factors, prominent clinician-researchers Judith S. Currier, M.D., M.Sc., and Priscilla Hsue, M.D., argue in a perspective piece published in Journal of Infectious Diseases. Evaluating anti- and pro-inflammatory cytokines could help identify those at risk of myocardial infarction who do not have high blood pressure, elevated cholesterol levels, or similar issues, the authors state.

Currier and Hsue were commenting on a case-control study of pro-inflammatory Interleukin-1 in 237 people living with HIV (PLWH) with and without myocardial infarction, and an observational study of anti-inflammatory Interleukin-10 in PLWH and uninfected controls. The studies were also published in Journal of Infectious Diseases.

Results showed that in PLWH, IL-1 activation seems to indicate infarction risk while IL-10 appears to protect against heart disease. However, drugs that simply target inflammation via these pathways risk undercutting immunologic control of HIV, the perspective authors explained. They called for further research into the role of inflammation in HIV-associated atherosclerosis.

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Gene-Edited Babies May Face Shorter Lifespan in Effort to Protect Against HIV

Beyond its obvious ethical problems, genome editing to protect children against HIV may result in a shorter lifespan, a study published in Nature suggested.

Researchers analyzed death records and genomic information for 409,693 people in a British database. They found that those who naturally have two mutated copies of the CCR5 gene -- similar to what a Chinese scientist claimed in 2018 to have changed in the genome of twin babies -- face a 21% higher rate of death before age 76 than those who do not have that mutation.

People with the genetic change, CCR5-Δ32, miss a segment of the CCR5 gene involved in HIV binding, explained an associated press release. While that mutation keeps them from acquiring HIV and may protect them against certain other viruses, it also quadruples their chance of dying from influenza and may have other, as yet unknown, effects. "In this case, the cost of resistance to HIV may be increased susceptibility to other, and perhaps more common, diseases," study authors concluded.

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Universal HCV Testing and Treatment Is Cost-Effective -- But Not Enough for Prison Budgets

A strategy that tests everyone entering a U.S. prison for hepatitis C (HCV), treats all who are found to have HCV, and links those people to care upon release can be cost-effective at current prices for newer HCV drugs, a simulation published in Clinical Infectious Diseases found.

Between 17% and 23% of people in prison or jail have HCV, compared to 1% of the general population, according to the Infectious Disease Society of America. The model was based on data from the Washington State Department of Corrections (WADOC) and compared various strategies:

  • HCV testing: 1) everyone at entry or release; 2) test only those with indications for HCV; 3) do not test anyone.
  • HCV treatment: 1) treat everyone; 2) treat only those with advanced liver fibrosis; 3) treat no one (if nobody is tested).

While the "test, treat, and link all" strategy was found to be cost-effective from a public health perspective, it is still too expensive for many prison budgets, study authors acknowledged. For example, in 2016 that strategy would have consumed 89% of WADOC’s annual medication budget. "Addressing HCV in prisons will require investment in correctional health and partnerships, including with public health departments," authors concluded.