Looking Ahead From IAS 2019: New Hope For HIV Prevention and Treatment

The 10^th IAS Conference on HIV Science in Mexico City had a strong scientific program with new data on many important issues, including the women’s health topic of ART in pregnancy, expanding options and tools for prevention, and the announcement that several cities have reached the 90-90-90 goal. With expanding treatment and prevention options--specifically for special populations--this gives me hope that achieving the target is possible globally. Here are my highlights from the meeting.

Dolutegravir Considerations for Women
IAS 2019 featured important data on the association of dolutegravir (DTG) with neural tube defects (NTD).

Preliminary data from the Tsepamo study in Botswana first alerted the world to the possible link in 2018. In the pre-May 2018 analysis, the prevalence of NTD among women who conceived while receiving DTG was 0.94%.

However, in the updated analysis presented at IAS 2019, the NTD prevalence was 0.30%, with 1 NTD reported among the additional 1257 women exposed. While this was lower than previously indicated, this incidence remained higher than the 0.10% incidence of NTDs observed in women receiving non-DTG ART during conception.

Another Botswanan study presented at IAS 2019 reported 1 case of NTD among an additional 152 Botswanan women receiving DTG at conception, while no cases were reported for the 381 women receiving non-DTG ART during conception.

However, a retrospective cohort study of Brazilian women with HIV found no NTDs among births to 384 women with possible exposure to DTG at conception between 2017 and 2018.

Continued surveillance and additional data are needed to understand if there are other risk factors involved in the increase in NTD with DTG observed in Botswana, such as folic supplementation, and also to generate comparable data for other ARVs.

Based on these findings, the WHO reconfirmed the use of DTG-based ART as preferred first-line and second-line therapy. The updated guidelines state that for women of childbearing potential initiating ART, the benefits of DTG--including better viral suppression, fewer maternal deaths, and fewer sexual and mother-to-child transmissions--likely outweigh the risks associated with DTG.

Importantly, they stress a woman-centered and rights-based approached, in which women are provided information about benefits and risks to make an informed decision regarding ART use.

I believe this is the most important message of these data: we should ensure our female patients are aware of the risks and benefits of using DTG and decide together what her best treatment option would be.

Enhancing Prevention Options
IAS 2019 also focused on new and improved options for prevention. The ImPREP study assessed same-day PrEP with TDF/FTC in men who have sex with men (MSM) and transgender women (TGW) in Brazil, Mexico, and Peru at high risk of HIV infection. The study reported high early continuation and adherence rates (79.6% and 97.2%, respectively).

However, these rates were lower for TGW and young persons between the ages of 18 to 24, shedding light on the need for tailored approaches for these more vulnerable populations.

Altogether, ImPREP did provide proof-of-concept that same-day PrEP is feasible in these special populations and in this region, in which the prevalence of HIV among MSM and TGW is the most concentrated in Latin America.

Another exciting agent in development for HIV prevention is the islatravir drug-eluting implant, which investigators reported was well tolerated in a double-blind, placebo-controlled, phase I trial. Pharmacokinetic analyses and modeling from the trial projected that the implant would provide sufficient HIV prophylaxis for ≥ 1 year. More prevention options such as this give a sense of hope that we will continue improving methods to eliminate HIV.

Hope
To me, hope was the common theme of IAS 2019. Hope that the 90-90-90 by 2020 target is feasible with continued effort and hard work. (Even though most of the world has not reached this goal, we can continue to learn from the areas that have reported success.) Hope that new tools for treatment and prevention will help us get there. Hope that effective treatment strategies are suitable for different types of patients, such as women of childbearing age. Hope that the end of HIV is possible.

Join the Discussion
What data from IAS was most exciting to you? Which presented strategies do you think will have the greatest impact on the epidemic? Join the discussion by posting your comment below. For more details on this and other key studies from IAS 2019, review more conference coverage, including CCO’s summary slidesets and check back soon for audio from a series of post-conference webinars.