This Week in HIV Research: The Importance of Challenging Our Assumptions
It’s natural for us to make assumptions. There’s a limited amount of time in a day and energy in our souls; once we ingest a new piece of information and successfully apply it to our clinical practice (or health policy), it becomes a part of our baseline approach, like a colony of ants establishing a pathway to a new food source. The urge can become strong to resist altering that path.
Problem is, new data are being released all the time, and the cultural and scientific underpinnings of our prior conclusions are constantly shifting. There’s a delicate balance to strike between becoming so rigid that we can’t evolve our care and becoming so uncertain that we paralyze ourselves.
That’s part of why we created resources like This Week in HIV Research: to help filter some of the data and focus on new findings that may be the most pertinent in potentially altering HIV-related care practices or policy. We’ve got a few of those items for your consumption in our latest recap of recently published research, including:
- A reminder that very high hepatitis C treatment response rates can be achieved among people who are currently using substances.
- Data driving home the point that Black people can’t be treated as a monolith when devising HIV prevention and treatment interventions in the U.S.
- Compelling findings on the success of self-administered imiquimod relative to excision for treatment of anal high squamous intraepithelial lesions.
- Proof of concept that pre-exposure prophylaxis (PrEP) uptake can be effectively integrated with syringe service programs.
Let’s head down each of these research paths together. To beat HIV, you have to follow the science!
HCV Treatment Can Succeed Regardless of Ongoing Drug Use
High rates of sustained virologic response (SVR) to direct acting antivirals are achievable among people who use drugs or alcohol, a small study published in Open Forum Infectious Diseases found.
The INCLUDE trial involved 60 participants with HCV who use drugs or alcohol (47 of whom were coinfected with HIV) living in the Denver, Colorado, metropolitan area. They were randomized to receive 12 weeks of either wirelessly observed or video-based directly observed therapy with ledipasvir/sofosbuvir (Harvoni). Substance use, most commonly marijuana, was detected in urine samples at 94% of in-person visits.
At study end, 87% of participants had achieved SVR by intention to treat criteria, and 95% in an as-treated analysis. Median adherence was 96%, with better results in the video observation than in the wireless arm.
Missed doses between study visits were more likely among participants who were also living with HIV, those who used methamphetamine or cocaine, and Black people. Using marijuana was actually associated with fewer missed doses, possibly because visits in which marijuana was detected also found less methamphetamine use, study authors theorized. The researchers also noted that most Black participants were also living with HIV, and that they exhibited higher rates of cocaine and marijuana use than non-Black participants.
“Our findings support expanding DAA treatment to [people who use drugs] to eradicate HCV and the use of technology-based measures to facilitate treatment uptake in this population,” study authors concluded. They also suggested additional research into several topics: adherence patterns in people using specific drugs, socioeconomic barriers or comorbidities that may elucidate the observed racial disparity, and how forgiving of missed doses specific DAAs are.
Late HIV Diagnoses Among Black People Highest in Rural Areas
Considerable geographic and sex-based disparities exist when assessing HIV care outcomes in Black communities in the U.S., the Centers for Disease Control and Prevention reported in Morbidity and Mortality Weekly Report.
The study featured data from 41 states and Washington, D.C.; Arizona, Arkansas, Connecticut, Idaho, Kansas, Kentucky, New Jersey, Pennsylvania, and Vermont were not included in the analysis. In 2018, 43% of new HIV diagnoses in those 42 jurisdictions were among Black people; of these, 77% were linked to care within one month of diagnosis and 63% were virally suppressed within six months, substantially lower than Ending the HIV Epidemic targets or UNAIDS’ global 90-90-90 goals.
Of the 14,502 Black people diagnosed per the report, 6% lived in rural settings, 13% in urban areas, and 81% in metropolitan areas. Late-stage diagnoses were more common in rural areas—especially among women of all races, who accounted for 31% of such diagnoses, compared to 19% among metropolitan men.
Other key findings include:
- Independent of location, people 45 years old and older were more likely not to learn their serostatus until advanced disease.
- Men were less likely to be linked to care or virally suppressed than women.
- This was especially true for men who acquired HIV through heterosexual contact; they also had the highest rate of late diagnoses by transmission category.
“For equitable health to be achieved for Black persons in all geographic areas, culturally appropriate and stigma-free sexual health care is needed, particularly among those who live in rural communities,” study authors commented.
Self-treatment of high squamous intraepithelial lesions (HSIL) was more successful than surgical excision in a study of 405 men who have sex with men (MSM) living with HIV, Spanish researchers reported in PLoS One.
All participants were screened for anal mucosa dysplasic lesions, and 88 had HSIL, the precursor to anal squamous-cell carcinoma. HSIL incidence dropped precipitously from 43% in 2010 to 4% in 2018, although the earlier timepoint was based on a small sample, 9/21, compared to 10/254 by study end. (Eleven participants were lost to follow-up.)
The risk of HSIL was greater among those with a low CD4 nadir or a history of AIDS. Study authors recommended screening for anal dysplasia in MSM with a late-stage HIV diagnosis.
Among participants with HSIL, self-administration of 5% imiquimod three times a week for 16 to 18 weeks had a higher response rate (97%, compared to 73% for surgical excision), required fewer re-treatments, and was associated with fewer adverse events than surgical excision of the lesions. No patients progressed to ASCC, whether they were treated with surgery or imiquimod.
PrEP Integration With Syringe Services Is Feasible
Integrating PrEP with a syringe services program for women who inject drugs is feasible, a small demonstration study reported in Journal of Acquired Immune Deficiency Syndromes showed.
The study included 95 HIV-negative women who took part in programming at a Philadelphia syringe services program (SSP). Most participants were white and cisgender; 63 of the 95 ultimately accepted PrEP. Uptake was higher among those who accessed the SSP more often, reported inconsistent condom use, or had experienced sexual assault.
At week 24, 42 women had been retained in the study. Retention was associated with more frequent visits to the SSP. Qualitative interviews with 25 participants also found that a history of sexual assault motivated acceptance of biomedical HIV prevention. Study authors called on SSPs to provide post-assault care, and on researchers to further study the intersection of trauma and PrEP uptake, which can inform future designs of targeted prevention programs for women who inject drugs.
Self-reported PrEP adherence was higher than what was documented through urine-based testing. Point-of-care adherence tests could help providers deliver individualized counseling or positive reinforcement, study authors suggested. They also suggested a pilot study into same-day PrEP start for women who inject drugs to counteract the early drop-out rates seen in the current study.
The study authors also offered a few additional factors that, based on the study experience, other SSPs may want to keep in mind if they are considering integration of PrEP into their services:
- Phlebotomy challenges because of collapsed veins and scarring from injecting drugs.
- PrEP costs, although helping clients to enroll in health insurance programs may mitigate that issue.
- The need for culturally specific programs aimed at women who do not match the demographic characteristics of this particular cohort.