By Benjamin Ryan
Pregnant women with HIV have a much higher risk of transmitting the virus to their newborns if they are coinfected with hepatitis B virus (HBV) and have a high hep B viral load, aidsmap reports.
Presenting their findings at the 2019 Conference on Retroviruses and Opportunistic Infections in Seattle, researchers retrospectively analyzed data from the HPTN 046 trial, which ran from 2007 to 2010 in sub-Saharan Africa and studied the effects on mother-to-child HIV transmission rates of providing infants of HIV-positive mothers with six months of the antiretroviral (ARV) Viramune (nevirapine) versus a placebo. During the trial period, it was common for pregnant women with HIV in this region not to receive ARV treatment for that virus.
The new study’s authors studied stored samples from the pregnant women to see whether they had hep B upon entering HPTN 046 and also to determine their HBV viral load upon delivery. They defined a high viral load as 1 million or higher and a low viral load as less than 1 million.
A total of 2,016 mothers and their 2,041 infants were included in the analysis. Eighty-eight (4.3 percent) of the women had HBV. They each had one newborn, and the group of babies was evenly divided between the placebo and Viramune arms. The women had a median age of 27 years old.
After adjusting the data to account for differences between the women according to CD4 count, age and their own use of ARV treatment, the researchers found a higher rate of low birth weight among the babies of women who had a high HBV viral load (30 percent of such infants, or 3 in 10) compared with the newborns of women who did not have hep B (6 percent of such infants, or 5 in 78). However, this difference was not statistically significant, meaning it could have occurred by chance.
After parsing the data more closely, the researchers found that having a hep B viral load above 100,000 at delivery was associated with low birth weight.
Twenty percent (2 of 10) of the mothers who had a high hep B viral load transmitted HIV to their newborns compared with 4 percent (53 of 1,953) of those who did not have HBV and none (0 of 78) of those who had a low hep B viral load. These differences were statistically significant. Compared with the women who did not have HBV, those with a high hep B viral load were 6.75 times more likely to transmit HIV to their newborns. There was no difference in the mother-to-child HIV transmission rate between those without hep B and those with a low HBV viral load.
SEATTLE, WASHINGTON—The recipe for ending HIV epidemics seems straightforward. Introduce widespread testing. Immediately put those who test positive on antiretroviral (ARV) drugs, which suppress the virus to undetectable levels so those people won’t infect others. The number of new infections will drop, and the epidemic will peter out.
But massive, costly studies done in the past few years have failed to show this strategy can reliably curb the spread of the virus, to the frustration of researchers. The latest and largest ever study presented here last week at the Conference on Retroviruses and Opportunistic Infections did show a modest benefit. But confusingly, there was almost no decline in infections in the study group where it was most expected.
Ending the HIV/AIDS epidemic may be harder than anticipated, it seems. “ARVs on their own are not the magic bullet,” says Collins Iwuji, an epidemiologist at Brighton and Sussex Medical School in the United Kingdom who helped run one of the earlier studies, a South African treatment as prevention (TasP) trial.
The new study, called Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART), included 1 million adults in Zambia and South Africa. When it began in late 2013, research had shown that ARVs can not only stave off disease, but also prevent people from infecting others. But whether these benefits would translate from an individual to an entire community was unclear.
PopART randomized 21 communities into three arms. One received annual house-to-house HIV testing and immediate treatment for those infected (A); another got the same testing, but treatment followed existing country guidelines and was offered only to HIV-infected people who already had evidence of some immune damage (B); and the third got no intervention from the study (C).
After 3 years, an analysis that sampled more than 12,000 people in each of the three arms found group B had 30% fewer new infections than group C. But in arm A, where presumably even more people were treated, the researchers found only 7% fewer infections than in arm C, which wasn’t a statistically significant difference. “When we first saw the results we thought it was the other way around, that arm A and B results got reversed,” says Richard Hayes of the London School of Hygiene & Tropical Medicine, who headed PopART. “We had four statisticians review the data. It’s true I’m afraid.”
“We have a lot of work to do” to explain the unexpected outcome, he adds. Among the factors that could have boosted the infection risk in A are migration of infected people, clustering of sexual networks that had highly infectious individuals, or more sexual risk taking.
François Dabis, who heads the French Agency for Research on AIDS and Viral Hepatitis in Paris and was the principal investigator of the earlier TasP study, says he’s heartened that PopART at least found an impact in arm B. TasP compared immediate treatment with treatment according to South African guidelines; the results, published last year, showed no population benefit from immediate treatment at all, likely because many people who tested positive didn’t seek the free care available.
SEARCH, a large study staged in Kenya and Uganda that used health fairs to do community-wide testing, had more success getting infected people on treatment. But SEARCH investigators reported last summer that they, too, had come up empty-handed. In the middle of the trial, the two countries adopted new World Health Organization (WHO) guidelines recommending that all HIV-infected people get treatment immediately, effectively robbing the study of its control group. (WHO’s recommendations complicated analyses in PopART and TasP as well.) A fourth study in Botswana did find a 30% drop in new cases from widespread testing and treatment, but it had far fewer people and barely reached statistical significance.
Diane Havlir of the University of California, San Francisco, one of SEARCH’s principal investigators, welcomes one clear message from the studies: that widespread testing has the power to identify the majority of infected people, an essential component of the “Ending AIDS” agenda. “We are one step closer and have data for the next steps,” Havlir says.
Nor is anyone ready to give up on universal treatment. “We’re not going in the wrong direction,” Dabis says. “What we’re saying is it’s more complex to achieve reductions in incidence than we anticipated.” Like many others, he says offering ARVs as pre-exposure prophylaxis to people at high-risk of infection is a key missing component of these studies.
SEATTLE – A new and shorter drug regimen to prevent tuberculosis illness can safely be given to people with HIV who are on antiretroviral treatment regimens that include dolutegravir, researchers here announced. The finding is good news for people living with HIV for two reasons.
The new regimen – consisting of the TB drugs isoniazid and rifapentine – treats the inactive form of TB infection before it can cause illness in people living with HIV taken once a week for three months – a big improvement over the standard regimen that requires taking pills every day for six months. Rifapentine, however, is known to reduce concentrations of other drugs when taken concurrently, complicating access to the preventive TB regimen for people on most antiretroviral treatment regimens. In addition, leading to viral suppression faster, fewer side effects and less risk of resistance, dolutegravir is a widely preferred drug in any case.
The findings may pave the way for accelerating efforts to combat TB infection among people living with HIV, Kelly Dooley of Johns Hopkins University said, as TB remains the biggest killer of people infected with HIV.
Researchers provided the standard dose of dolutegravir to 60 study participants for two months, followed by three months of once-weekly rifapentine and isoniazid, and found that while dolutegravir concentration was slightly reduced, there was no change in viral load suppression one month after the completion of TB treatment when compared to baseline levels, researchers said. Researchers did not have to increase the dose of dolutegravir to maintain viral suppression.
“We now know that it’s safe to take these two game-changing regimens together.” Dr. Dooley said.
Every day, 460 adolescent girls become infected with HIV and every week 350 adolescent girls die of AIDS-related illnesses
GENEVA, 8 March 2019—On International Women’s Day, UNAIDS is urging countries to step up and protect young women and adolescent girls from HIV.
AIDS-related illnesses remain the leading cause of death for women aged 15–49 years globally. In 2017, 66% of new HIV infections among 10–19-year-olds were among females globally—in eastern and southern Africa, 79% of new HIV infections among 10–19-year-olds were among females.
“There is a vicious cycle of gender inequities, gender-based violence and HIV infection in many parts of the world,” said Michel Sidibé, Executive Director of UNAIDS. “Oppression and power imbalances must be reversed and harmful masculinities addressed in order to ensure that women and girls have full control over their sexual health and rights.”
Much more needs to be done to reach young people with HIV prevention, treatment and care. Young women and adolescent girls are especially being left behind. Gender-based violence, sexual exploitation and drug use are among the many factors that can increase the vulnerability of young women and adolescent girls to HIV.
Efforts to end AIDS are undermined where the human rights of young women and adolescent girls—especially their sexual and reproductive health and rights—are not supported. Countries must therefore enact laws and policies that enable access to services, including health and social protection, by young women and adolescent girls, helping them to claim their right to health.
International law gives people, including young women and adolescent girls, the right to access services to protect their sexual and reproductive health. However, 45 countries worldwide still have laws that require people under the age of 18 years to obtain the consent of their parents in order to be tested for HIV.
Social protection, education—including comprehensive sexuality education—and HIV prevention services that are integrated with sexual and reproductive health services have been shown to improve the health of, and empower, young women and adolescent girls. A South African study showed that HIV prevalence among girls who had finished high school was about half that among girls who had not (8.6% versus 16.9%). Children who access universal primary education in Botswana, Malawi and Uganda have been shown to have similar outcomes.
Investing in education. Investing in HIV and other health services. Preventing and protecting women and girls from violence. Eradicating harmful practices such as early, forced and child marriage. Promoting women’s rights. Through these actions young women and adolescent girls can be protected from HIV and the world can build towards ending AIDS by 2030.
For more information on the UNAIDS work on young women and adolescent girls please visit http://www.unaids.org/en/topic/gender
Women with HIV may have higher breast cancer mortality
A study from Botswana, presented at CROI 2019, found that HIV-positive women with breast cancer appear to have decreased survival rates compared with HIV-negative women. Having HIV was associated with a nearly twofold reduction in survival.
While prior research in the US and Africa has found that women with HIV do not have higher breast cancer incidence, or likelihood of developing cancer, some studies with a small number of HIV-positive participants suggested that survival may be reduced.
This prospective analysis drew from the Thabatse Cancer Cohort, which enrolled nearly 4000 people with cancer at four major oncology centres in Botswana. Participants are evaluated at study entry and followed for five years. The breast cancer cohort included 510 women who sought cancer care between October 2010 and September 2018. Of these, 151 were HIV positive and 327 were HIV negative.
The women in the HIV-positive group were a few years younger than the HIV-negative group, on average, but the two groups were similar in terms of breast cancer stage and type. Types of cancer treatment also did not differ significantly by HIV status. The majority of the women living with HIV were taking HIV treatment and around 70% had a viral load below 1000 copies/ml.
During the course of the study, 70 HIV-positive women (46%) and 101 HIV-negative women (31%) died. In a multivariate analysis controlling for other factors, HIV-positive women had an 82% reduction in survival compared with HIV-negative women.
Dr Katrin Sadigh, presenting, emphasised that survival was poor for both HIV-positive and HIV-negative women in this study, and better strategies are needed to speed up diagnosis and improve care.