What's New or Notable in HIV Treatment and Prevention Adherence?

Program Director, New Orleans Regional AIDS Planning Council

In one session [entitled "Why Are There Still Such Large Gaps in Coverage in the Test and Treat Era?," Mark Nelson, M.D., of Chelsea and Westminster Hospital in the UK] talked about the "steep fall clinics" in London. In London, they don't have any government-sponsored PrEP [pre-exposure prophylaxis] whatsoever. If you want PrEP, you have to go online, pay for it out of your own pocket -- that's on the side when it comes to their prevention efforts.

What they have been doing in these specific clinics is getting many more people in for new, first-time testing and, for those most at risk, doing more frequent repeated testing. The frequency of testing, plus testing everybody, was really showing that their rate of new transmissions was plummeting -- simply from a prevention-with-positives approach, getting them on antiretroviral therapy ASAP, testing the bejesus out of people -- that was an eye-opener for me.

In New Orleans, [seeing no reduction in new HIV cases in recent years, despite improvement in viral suppression rates and other measures], I've really been stumped, and I've very much been attributing it to stigma. It was Jorge from Apoyo Positivo in Madrid who [during his presentation] put up the slide: It's "all about STIGMA" (pictured). That's usually my theory. But I could also see where, if you can get past that enough to get people tested, and have them coming in for testing frequently, and do that counseling and that risk reduction frequently, that can raise education, awareness, break down the stigma -- it can do so much. I was really into that information.

Image credit: Olivia G. Ford.

Los Angeles County Department of Public Health

There are a few things that were key to me. One was a study that was done through the University of California San Diego, where they looked at meth use and the association with PrEP adherence: They found no significant association between meth use and PrEP non-adherence.

I get a lot of providers saying things like, "Oh, a patient's not going to take their PrEP if they're on meth," or "They're not going to be adherent to PrEP because they have substance use on board."

So, I think this is a great study to be able to use in those conversations: Every patient, although they may be using other substances, may still find time to take their PrEP -- and be able to decrease their risk of HIV.

Image credit: Olivia G. Ford.

HIVE, San Francisco, Calif.

We presented a poster from HIVE about our postpartum death review -- which is a really meaningful piece of work that Karishma Oza, [M.P.H.,] our HIVE coordinator, led. It looked at nine women who had died postpartum.

In San Francisco, we really pat ourselves on the back about having no perinatal transmissions since 2004. Yet, there's this other story, right? The N for our poster was 9, so it's a small number, but still really meaningful for us in terms of looking at trauma-informed care.

So, I'm thinking a lot more about postpartum retention in care, and I was thrilled to see, at this conference, several other posters and research about that. Mississippi looked as a state at postpartum deaths. These two posters were catty-corner from each other, and it was nothing short of sobering. I think, then, you see the reality of women's lives, and this shadow side of the success of perinatal HIV prevention that no one is talking about.

Image credit: Vincent Carrella.

Montefiore Medical Center, Bronx, N.Y.

We can make providing PrEP to patients more easy, and [do it] in a more streamlined fashion. Bob Grant, M.D., M.P.H.'s presentation mentioned that monitoring renal function may only be needed in people over age 40 and that HIV screening appears mainly useful upon (re)initiating PrEP after an HIV exposure. This has made me think about potential changes we can make in my clinic to make PrEP far simpler for patients and providers.

I was really surprised at the paucity of studies focused on PrEP and women (both cis and trans), given how underutilized PrEP is among women. Highlighting this point, an abstract was presented that reported low PrEP awareness among women of color in NYC (about 25%); in contrast, another abstract reported PrEP awareness among of men who have sex with men of 95%. So, much more work is needed to get the word out about PrEP to women who most need it.

Image credit: Clinical Education Initiative.

Longtime Community Advocate, Greensboro, N.C.

Regarding 90-90-90: I am starting to understand it -- I don't know if we're going to make it. I have observed at this conference, and at other conferences, areas that are on the cusp of making it. I'm trying to figure out what they're doing to help them get there that we aren't doing back home in North Carolina. As I understand it, the rate of new HIV transmissions in Charlotte, North Carolina, is higher than that in San Francisco. I have my suspicions as to what they're doing that we're not doing in the South.

One of those suspicions is that we don't have our elected officials on board; we don't have Medicaid expansion; we've got this conservative Southern strategy where some of us still can't believe we've lost the Civil War. In the South, there isn't that political will.

Image credit: Olivia G. Ford.

Medical University of South Carolina's Ryan White HIV/AIDS Clinic, Charleston, S.C.

I thought Thomas Giordano, M.D., M.P.H.'s talk about same-day antiretroviral therapy initiation and the evidence around same-day starts was really interesting.

I had always looked at the positives: Patients are getting into care quickly and so might have more enthusiasm, and maybe that would lead to longer-term interest and retention in care. But he also pointed out a lot of the potential negatives and limitations. [For instance,] in a study setting, you have the medications available, but outside the study setting, you have a lot of other steps that involve applying for AIDS Drug Assistance Program [help] in getting medications. So, there are plusses and minuses, but I think the overall idea [is] that getting people on medications faster not only decreases community viral load and transmission but also engages patients in their acceptance of the diagnosis, potential disclosure of the diagnosis, and interest and trust in the health care setting.

Image credit: Olivia G. Ford.

APEX Family Medicine, Denver, Colo.

I am a family nurse practitioner and am just finishing my first year as a new HIV care provider. At APEX, we have the ability to provide centralized (and nonjudgmental) care -- we understand that sexual health is essential to understanding the comprehensive clinical picture of an individual, and thus normalize and discuss routinely HIV/sexually transmitted infection screening, initiate conversations surrounding HIV prevention, and if diagnosis does occur, there is immediate linkage to treatment with provider continuity within APEX, as we are well-versed in HIV prevention and treatment. However, what I have been overlooking is the linkage to support services (as part of comprehensive care).

At the conference, I was exposed to a variety of interventions and resources that have been shown to improve quality of life, medication adherence, care retention, etc., in those living with HIV; although some are not necessarily relevant to the needs of APEX's patient population, many of them are, such as asking the patient while in clinic to identify a consistent individual (or individuals) who may assist in improving accountability for attending appointments, which I have now done with a few of my patients with a well-received response.

I feel so fortunate to have had the opportunity to meet and speak with individuals who have upheld, and charged others with, the social responsibility to advance the HIV care continuum; I am humbled to join this welcoming family.

Image courtesy of APEX Family Medicine.