Blogs2 March 2018

As the final symposium of the Conference on Retroviruses and Opportunistic Infections (CROI) begins, and after hearing about all of the new research predominantly in HIV over the last 4 days, it’s hard not to wonder where it’s all pointing. Fortunately, one of the final symposia sought to provide an answer - ART: The Next 25 Years.

The general themes discussed at the conference would be to say that in general, we are doing quite well with controlling incidence of HIV in MSM in the developed world, the caveat being hot-spots of predominantly Black and Latinx men, or White guys who inject drugs. We’re not doing so well with women in general, particularly in the African setting, and the pregnancy/post-partum complex is perhaps more ominous that we’d initially thought. All of this is constructive, however, and allows us to check the temperature, so to speak, and re-evaluate our approaches to HIV management. 

With wide access to needle and syringe programs, opioid subsitution therapy and hepatitis C treatment, Australia is leading the world in the elimination of hepatitis C. However, an emphasis on active case finding and continuing to move treatment into primary care is essential to maintain our momentum.

This Symposium on the Next 25 Years of ART outlined the move towards injectables, broadly neutralizing antibodies and posited a shift in attitudes towards the treatment of children, championing their inclusion in clinical trials.

Liver cancer is one of the only cancers in Australia where rates are rising. Most liver cancers have a preventable cause, and increasing screening and treatment for hepatitis B and C will help us to curb the rates of liver cancer.

While the USA has seen increasing rates of acute hepatitis B and hepatitis C, as well as increasing cases of HIV linked to injecting drug use, other parts of the world such as Australia are on track to eliminate hepatitis C. 

There is continuing controversy about the clinical effect of HIV in the brain. This session sought to examine the effects of cART, started early or not, on both the physical health of the brain and mental health of the patients. 

Increasing the uptake of testing, especially among those at high risk or who rarely test, is one of the underpinning strategies to reach the 90, 90, 90 goals. Self-testing has enormous potential in Australia to reach these groups, however must be implemented with care. 

This afternoon’s series of lectures on the future of PrEP were incredible, and I was left reflecting on the future of PrEP in Australia. PrEP works, it really does, and I was compelled by Roel Coutinho to believe that if the correct risk groups are targeted, HIV indeed could be eradicated from Australia. There is evidence for increased transmission of STIs, but PrEP is ‘a sexual health program, not a drug’, as was eloquently conveyed by Julia Schillinger, and with PrEP there is a duty to increase testing. Linda-Gail Bekker reminded us that PrEP should be a lifestyle choice rather than a medical intervention, and there needs to be a client centred approach. And, perhaps most relevantly, Nellly Mugo talked about being community centred and integrating PrEP into other programs in the scale-up process.

The mind and body are one! Overall good health must include mental health. If we do not address the mental health of HIV infected individuals, we will not achieve our goal of diagnosing 90% of all patients who are HIV infected, making sure 90% of HIV patients are having their antiretroviral medication, and 90% having viral suppression. It is known that mental health conditions contribute up to ten-fold increase in the risk of acquiring HIV infection. This is due to the fact that people suffering with a mental illness are more likely to have high risk behaviour, less likely to get a sexual health screen, more likely to have poor adherence to treatment, thus leading to a poor health outcome.

• The World Health Organisation considers depression to be the leading cause of disability globally, with anxiety rating 6th. 
• 4.4% of the world’s population is thought to be living with depression, but estimates show that at least 50% of people living with HIV/AIDS (PLWHA) satisfy criteria for at least 1 mental or substance use disorder.
• Risk-associated behaviour and poor health care adherence increases in people with depression particularly.
• Depression is the most prevalent mental illness amongst PLWHA.
• Mortality rates in PLWHA diagnosed with a Major Depressive Disorder (MDD) are double when compared with those not diagnosed with MDD.
• Lengthier durations of MDD are associated with increased mortality, and this is thought to be due to chronic inflammation causing tryptophan deficiency and as a result serotonin deficiency.
• Meta-analyses show adherence to the HIV model of care in PLWHA with depression is a significant barrier to treatment (15% adults, 25% in adolescents). 
• Whilst multiple validated screening tools exist for mental illness and multiple modes of therapeutic intervention also exist these are not being employed reliably.