START Prompted New HIV Guidelines: Did Treatment Deliver?

Heather Boerner

October 19, 2017

MILAN — Evidence from the Starting Antiretroviral Treatment Early Improves Outcomes for HIV (START) trial showed that treating people for HIV immediately after they test positive could ease the burden of the disease around the world. Now, 2 years later, at the European AIDS Conference, researchers will report just how far Europe has come.

"Most European guidelines changed in 2015, to a great extent based on START," said Jens Lundgren, MD, from the University of Copenhagen.

"For the first time ever, there are emerging data on declines in the number of new diagnoses among men who have sex with men in several European countries," he told Medscape Medical News.

Fulfilling the Promise of START

The first of these data were published earlier this year (Euro Surveill. 2017;22:30553), and new data on whether that trend has continued will be presented by Noel Gill, head of the HIV and STI Department at Public Health England.

The meeting will also feature presentations on randomized, controlled trials — such as the dual-therapy SWORD-1, SWORD-2, and GESIDA 9717 studies — and additional data from the PROUD study on pre-exposure prophylaxis (PrEP) and the LATTE-2 study of long-acting-injectables.

But "the real world is so different from clinical trials," said Fiona Mulcahy, MD, from St. James's Hospital in Dublin, who is president of the European AIDS Clinical Society.

"We, as clinicians, are now asking ourselves: What models of care will be relevant going forward?" she explained. "How do we best deliver HIV care to patients who are, for the most part, doing relatively well on treatment, but whom we want to make sure won't fall out of care?"

There is hope that the real-world data to be presented — from the National Health Service in the United Kingdom and other programs — will shed light on how to make healthcare nimble enough to respond to the changing needs of patients, she said.

In addition, results from cohort studies will reveal the real-world effectiveness and adverse effects of tenofovir alafenamide (TAF), and resistance to and adverse events related to integrase inhibitors.

A variety of studies testing treatment switches, simplifications, and maintenance therapies — already in use or in clinical trials — will be presented, as will cohort studies that are consolidating the results of practices such as the prescription of dual-maintenance therapy.

"Our major focus is on clinical impact. Most presentations are from clinicians per se, who report on the real world and what's happening in the reality of each country," said Dr Mulcahy.

Women Making WAVEs

New this year will be a noncommercial preconference workshop called Women Against Viruses in Europe (WAVE). Models of care that work especially well for women living with HIV will be described, and PrEP for women will be discussed. The registration-only workshop has already elicited so much interest that meeting organizers have moved it to a larger venue.

Also drawing a lot of attention is a session on breast-feeding by women living with HIV, which was precipitated by the controversial Swiss decision that women who are virally suppressed should be allowed to breast-feed, said Dr Mulcahy.

"The rest of Europe is waiting to see," she explained. "Most people are behind it in the right circumstances." The real question is what to do when the circumstances are not perfect, she added.

HIV and the Comorbidities of Aging

"As patients get older, the big question is: Should HIV physicians be looking after non-HIV conditions?" said Dr Mulcahy.

As part of a session on geriatric conditions in patients living with HIV, clinicians will learn what new data — updated from a recent study (J Infect Dis. 216;5:545-553) — reveal about the management of stroke, as well as the management of osteoporosis and bone loss in menopausal women.

Again, the point here is to provide information that clinicians can use to change their practice and manage older patients, said Dr Mulcahy. "Unless you're up on the management of stroke, menopause, dementia, and Alzheimer's disease, you can't do that effectively."

Dr Mulcahy and Dr Lundgren have disclosed no relevant financial interests.

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