COMMENTARY

The Year in HIV: Prevention, Treatment, Complications, Cure

Paul E. Sax, MD

Disclosures

December 09, 2014

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This is Dr Paul Sax from Brigham and Women's Hospital in Harvard Medical School. Here, at the end of the year, I would like to review the top stories in HIV medicine for 2014. I have divided the topics into four categories:

Prevention

Treatment

Complications

Cure

Prevention

The biggest story of the year is the broader recommendation for the use of preexposure prophylaxis (PrEP). This comes from Centers for Disease Control and Prevention (CDC) guidance[1] that was issued this year and also from increased analysis[2] of the iPrEx study[3] showing that taking PrEP of at least four tablets weekly provides virtually 100% protection. This study was followed by the exciting study results of the PROUD study[4] and the Ipergay study.[5] The full data from both are expected in 2015.

Treatment

The biggest treatment study looked at initial therapy with raltegravir vs boosted darunavir vs boosted atazanavir (ACTG 5257).[6] The bottom line is that the best tolerated of the regimens was the raltegravir regimen, and it was the overall winner. This points us, at least in the United States, towards greater use of integrase inhibitor-based therapies for initial treatment of HIV.

Also in the treatment category, I would like to mention the nucleoside-limiting approach, such as that used in the NEAT study,[7] which looked at darunavir and ritonavir plus raltegravir. This combination performed fairly well but not quite as well in patients with high viral loads. In contrast, the GARDEL study[8] of lopinavir and ritonavir plus lamivudine showed that this two-drug treatment was just as good as triple therapy. There were also interesting studies of maintenance treatment with two drugs—the SALT study[9]—atazanavir and ritonavir plus lamivudine—and the OLE study[10] of lopinavir and ritonavir plus lamivudine.

The analysis[11] that looked at several ACTG studies is also worth mentioning. They found a nearly twofold increased risk for suicidality in efavirenz-treated patients. This post-hoc analysis used randomized trials, which strengthens the possible association. We should be using efavirenz with caution, if at all, in patients with a history of psychiatric illness.

Complications

This was the year that interferon-free therapy for hepatitis C arrived, first with sofosbuvir plus simeprevir,[12] followed by sofosbuvir plus ledipasvir.[13] The exciting news for HIV-infected patients is that it does not seem that HIV infection is a risk factor for failure of hepatitis C treatment, as long as the disease is stable and treated. You have to watch the drug-drug interactions.

Another important study for complications was the COAT study,[14] demonstrating in patients with cryptococcal meningitis that early treatment was associated with a worse outcome. This has been suggested before, but the COAT study is the largest on this issue, all but proving that we should be getting control of cryptococcal meningitis before starting antiretroviral therapy.

Cure

The patients who were thought to have been cured—the two stem cell transplant patients from Boston and the baby born in Mississippi—all relapsed this year, demonstrating that the prospect of HIV cure is going to be very difficult. These patients were studied intensively using the most advanced methods.

Those were the top stories in HIV medicine in 2014.

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