Highlights of the International Congress on Drug Therapy in HIV Infection, 23-26 October 2016, Glasgow, UK.

Introduction

Jürgen Rockstroh

The 2016 International Congress on Drug Therapy in HIV Infection brought together HIV clinicians, patient advocates and further stakeholders in the HIV research space to address new developments and innovations in therapeutic strategies and research impacting on the management of HIV infection. Although significant progress has been made and, for most HIV patients, if combination antiretroviral therapy (cART) is started early enough normal life expectancy can be achieved, there are still a number of challenges that accompany lifelong drug therapy. Also, new tools for prevention of HIV remain a hot topic in order to further curb the epidemic. Therefore, clearly the HIV cure agenda remains of utmost importance and was the focus of the opening lecture delivered by Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases [1]. Cure research has accelerated greatly over the past few years in two areas. The first is the prospect of eradicating the HIV reservoir altogether, i.e. a classic cure, which might involve novel latency-reversing and immunotoxic regimens, and gene editing techniques to create a host cellular environment that does not allow HIV replication. The second approach is the possibility of controlling HIV after stopping cART without eradicating the virus, which more recently has turned into a popular new area of research. In this context, he presented results from a study of an antibody against the cell receptor alpha 4 beta 7 integrin, the homing receptor for CD4 T cells. In this study, monkeys infected with the simian version of HIV were treated using antiretroviral therapy. They were then given the antibody, and treatment was discontinued. Almost 2 years later, the monkeys still had replication-competent virus but they had no viraemia. Although the exact mechanism of these findings remains unknown, these exciting results clearly inspire further research in this area.

Further important topics were tools that are available for ending the HIV epidemic. Treatment as prevention was covered by Julio Montaner, and new technology-based service-delivery models by Tarandeep Anand [2,3]. A special focus was on pre-exposure prophylaxis (PrEP), as PrEP with TDF/FTC recently became registered in Europe, but is still not financed in most European countries. Feedback from France and the US shows an increasing uptake of PrEP with continued good efficacy. Whether the risk for other sexually transmitted infections (STI), such as syphilis or acute HCV infection, increases over time will need to be further investigated. Of note, there are considerable disparities in the uptake of PrEP between black and white men who have sex with men (MSM) in the US, suggesting that the most vulnerable patient groups still have restricted access to PrEP at present. Pharmacological studies in a population at high risk of STIs, who cannot yet access PrEP, from the NHS in the UK, demonstrated convincingly that concentrations of TFV and FTC in generic formulations purchased over the internet were similar to those on the original formulation by Gilead [4].

Various sessions were devoted to HIV and ageing. These included the transition from HIV-infected children and infants to adult care (see summary by Pablo Rojo), as well as the complexities of medical care in adult HIV patients with increased risks of age-related conditions, such as fractures, cardiovascular disease, high blood pressure and diabetes. Indeed, as it is estimated that 50% of HIV-infected patients in Europe and the US will be above 50 years old by 2020, this is of growing concern. In this context, development of a new tenofovir formulation (tenofovir alafenamide), which appears to be less likely to cause bone mineral density changes or tubular toxicity compared with the former tenofovir fumarate formulation, was of interest, and discussed in the context of switch studies, which were presented here at the Glasgow conference for the first time [5,6]. In addition, the new European Aids Clinical Society (EACS) Guidelines were presented and discussed, which offer the advantage of a large section on comorbidity management, which is extremely helpful in clinical practice [7]. Overall, the management of these complex comorbidities requires a multidisciplinary approach to best take care of ageing HIV-infected individuals.

Finally, a large number of presentations covered new treatment strategies as well as new antiretroviral drugs in development. This included simplification strategies that looked at maintenance strategies with just one nuclease reverse transcriptase inhibitor (NRTI) (mostly 3TC) and a boosted protease inhibitor (PI), which may allow for improved safety and reduced treatment costs, or monotherapy with dolutegravir, which so far is believed to have a higher genetic barrier than other integrase inhibitors and may allow for a one-drug-only treatment option [8,9]. Indeed, no significant difference in rate of virologically suppressed patients was noted for the 3TC/PI/r arm, whereas some virological failures were observed in the dolutegravir-only maintenance study, which clearly emphasises that this strategy should not be employed outside of clinical trials at present. New data on new drugs or formulations included a subgroup analysis from the ONCEMRK trial that compared a new once-daily formulation of raltegravir with the old, twice-daily formulation, demonstrating comparable efficacy results independent from baseline CD4 cell count or viral load [10], and a subgroup and safety analysis from the new HIV1 attachment inhibitor BMS-663068, which continues to be developed by ViiV [11,12]. At week 96, virological response was generally similar for BMS-663068 and ATV/r in treatment-experienced subjects, regardless of sex, age, race, baseline viral load (VL) or baseline CD4 T cell count. BMS-663068 was generally well tolerated, with no BMS-663068-related AEs leading to discontinuation. This new drug remains of interest particularly for patients with multiple prior virological failures and extensive drug resistance as it offers the benefit of a new mechanism of action.

In conclusion, the Glasgow congress succeeded once again in providing an open forum where the ongoing challenges in HIV care and research were presented in excellent state-of-the-art lectures, discussed in great detail and hopefully will help to further improve HIV care overall.