This Week in HIV Research: Hep C, That Other Epidemic Within an Epidemic

A treatment-as-prevention (TasP) approach can be used to reach hepatitis C (HCV) elimination targets among people living with HIV, a Switzerland-wide program reported in Clinical Infectious Diseases showed.

The Swiss effort consisted of three phases:

1. HCV screening was systematically offered to men who have sex with men (MSM) in the Swiss HIV Cohort, which includes 84% of MSM living with HIV in the country.
2. Direct-acting antivirals were offered to those who tested positive for HCV.
3. HCV-negative MSM were re-screened and treated with DAAs, if necessary.

The program resulted in a 77% decline in the HCV incidence rate, although that effect was delayed past the end of the study period.

Initially, 80% of eligible MSM were screened, and 83% of those who tested negative for HCV were rescreened. Over a two-year period, 93% of 190 MSM who tested positive for HCV were cured of the virus.

Despite a massive effort in a high-resource country, not everyone was tested, study authors noted. Furthermore, there was a median 197-day delay in HCV diagnosis when HCV antibody testing was performed annually. “In the context of an elimination program, such a delay could be relevant because a timely diagnosis and, most importantly, immediate treatment initiation is crucial to avoid new HCV transmission to partners,” study authors noted.

Antibody testing may miss primary new HCV infections, Jürgen Kurt Rockstroh, M.D., of University Hospital Bonn in Germany, noted in a commentary. Those at high risk should have HCV RNA tests every three to six months, and behavioral interventions and harm reduction programs should also be offered, Rockstroh recommended.

Tenofovir concentrations in dried blood spots are not associated with the use of gender-affirming hormones, a small trial of directly observed PrEP among transgender men and women found.

The iBrEATHe study, published in Clinical Infectious Diseases, included in its final analysis 24 transgender men taking testosterone and 23 transgender women taking estradiol, with 38% of the women also taking spironolactone. Tenofovir diphosphate concentrations were compared between these two groups and with historical cisgender controls (17 women, 15 men). All participants took directly observed emtricitabine/tenofovir (Truvada) as PrEP for four weeks.

Tenofovir levels were comparable between trans women and trans men as well as between trans women and cis men, but were lower (by a mean of 23%) in trans men compared to cis women. Previously, the iPrEx trial had shown lower tenofovir concentrations in transgender women compared to MSM, but the trial was based on self-reported adherence, not DOT.

One limitation of the current study was the time frame, since it takes eight weeks to achieve steady-state tenofovir concentrations. That said, study data indicated that trans men, trans women, and cis men participating in the study were all on course to reach the necessary threshold of active drug at eight weeks. Further, the researchers found that tenofovir did not alter serum hormone levels among trans women or trans men.

Taken together, these results support current PrEP dosing recommendations for trans men and women—as well as messaging to the transgender community about the lack of interaction between hormones and tenofovir, study authors concluded.

In a related commentary, Douglas S. Krakower, M.D., of Beth Israel Deaconess Medical Center in New York argued that anti-stigma interventions among health care professionals and inclusion of genderqueer communities were also required. “If researchers and clinicians can develop and deliver PrEP in ways that meet the needs of transgender populations, then PrEP can be a cornerstone in the effective and equitable response to HIV that we need,” Krakower wrote.

A multi-pronged intervention called TEACH can improve guideline-concordant opioid prescribing for chronic pain in PLWH, researchers reported in Clinical Infectious Diseases.

The TEACH program (short for Targeting Effective Analgesia in Clinics for HIV) includes a nurse care manager who handles some of the necessary additional patient services, an interactive electronic prescribing registry, training, and access to addiction specialists for patient referral, if needed.

The study randomized 41 providers at clinics in Boston and Atlanta—and their 187 patients on chronic opioid therapy—to receive either the TEACH intervention or standard of care. Twelve months later, 71% of patients with providers in the TEACH arm had received two or more urine drug tests (one of the study’s primary outcomes) compared to 20% in the control arm. No significant difference was seen in early refill rates (the other primary outcome) between the two arms.

Among other study outcomes, opioid treatment agreements were more likely in the intervention arm, while there were no statistically significant differences in self-reported pain severity or HIV viral load suppression.

Study authors cautioned that during the study period, U.S. attention to its national opioid epidemic increased, which may have caused some providers to change their prescribing practices even absent an intervention. They also suggested that providers in the two arms may have talked to each other about the program, and noted that results of this two-city study may not be generalizable to the rest of the United States.

Nonetheless, “the TEACH intervention is a promising strategy to address chronic opioid therapy in HIV care,” study authors concluded.

A number of studies over the years have shown lower bone mass density in people taking tenofovir disoproxil fumarate (TDF, Viread), but whether such a decline results in more fractures has long been debated. Using a novel marker for bone microarchitecture, researchers argue in the journal AIDS that TDF may not increase fracture risk after all.

The marker, trabecular bone score, is derived from dual X-ray absorptiometry images taken with a specific device; it is an independent factor utilized in a common fracture prediction algorithm.

The study used data from the European ASSERT trial comparing bone health in treatment-naive PLWH starting on a regimen containing either abacavir (ABC, Ziagen) or TDF. At baseline, the score was calculated for 158 participants (75 on TDF, 83 on ABC); by week 48, it was calculated for 135 (65 on TDF, 70 on ABC).

Mean scores declined significantly over the study period, but there was no significant difference between the two treatment arms. Mean bone density also declined overall but dropped significantly more in the TDF arm.

Tenofovir alafenamide (TAF), a newer version of TDF, has fewer effects on bone health, but its impact on bone microarchitecture has not been well studied. Study authors called for evaluating TAF’s impact on the trabecular bone score, as well as correlating the score with bone density data and bone turnover markers for ABC, TDF, and TAF.