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BHIVA 2006

Gus Cairns

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BHIVA 2006 – selected studies

• People with CD4s <200 not getting treatment

• Africans, HIV testing and GPs• BHIVA mortality audit• Why gay men risk HIV• Caribbeans in London• And now the good news –

treatment durability

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People with CD4s <200 not getting treatment (abstract 01*)

• SOPHID database, 2004:– 14% (c. 4,900/35,000) seen for care had CD4s

<200– Of these 950 (19% or 2.7% of all patients) not on

ART– Substantial geographical variability:

• 36% in north-east: 9% in Northern Ireland– London:

• 490/20,674 had <200 CD4s and not on ART (2.4%). 118 had CD4s <50.

– Of the 490, 50% (244) had also not been on therapy in 2003…

» Of which over half had also had a CD4 count under 200 in 2003.

*Bryant, Chadborn et al. Adults with low CD4 counts that were not receiving antiretroviral therapy in England, Wales and Northern Ireland in 2004.

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Africans, HIV testing and GPs I (abstract 28*)

• Mayisha II survey:– 1359 members of African community in

London, Luton, West Mids. Questionnaire and anon Orasure test

• 50% of men and 40% of women had tested for HIV before

• 63% of those who tested positive (sorry don’t have prevalence) had had previous HIV test of which 54% knew they were pos, 32% last test negative, 16% did not specify result

• Reasons for not testing include fear of death and stigma (HIV associated with ‘misbehaviour’ and ‘immorality’)

*Elam et al. Barriers to voluntary confidential HIV testing among African men and women in England: results from the Mayisha II community-based survey of sexual attitudes and lifestyles among Africans in England

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Africans, HIV testing and GPs II (abstract 29*)

– Survey of 159 HIV+ Africans (60%♀) at 15 clinics

• Average 4 years in UK• 62% were late presenters (CD4 <200)• 84% registered with GP for median of 3 years;

¾ had seen GP in year prior to diagnosis• HIV testing only raised by 16% of GPs• When GP advised test, more than half of those

who tested said GP principal reason for testing• 30% previous neg test if which 1/3 tested in UK• 63% said ‘not expecting positive result’• 20% appear to have caught HIV in UK• 89% said ‘can trust staff at GUM clinic’ but only

37% said ‘can trust staff at GP surgery’• Only 30% had disclosed status to GP

*Burns et al. Could primary care be doing more?

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BHIVA mortality audit

– Annual questionnaire sent to all HIV treatment centres

– Last year 133 responded: 387 deaths between them

– 40 had not had a single death– Most common cause of death: bacterial

septicaemia (MRSA etc) – 13%• PCP: 10% • Non-AIDS cancers: 9% • NHL: 8% • Liver failure: 8% • Cardiovascular: 6%• TB: 5%

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BHIVA mortality audit contd.

• ‘Scenarios’ leading to death:

– Death not directly related to HIV: 30%.– Diagnosed too late: 24%– Under care but had untreatable complication:

17%– Poor adherence 11%– Chose not to receive treatment 5% – ‘Successfully treated but suffered

catastrophic event’: 3%– Unable to take treatment due to

toxicity/intolerance = 1%.– NONE treatment delayed because patient

ineligible for NHS care

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BHIVA audit contd.

• Clinics and death rate:

– Only 53 out of 93 centres reported any deaths due to late diagnosis.

– Smaller HIV clinics had proportionally more deaths due to late AIDS diagnosis

– Larger centres had more non-HIV-related deaths

– Why? • Because undiagnosed people turn up anywhere,

but larger clinics have older and more drug-experienced patients?

• Or because larger clinics are better at keeping late-presenting patients alive during critical early months?

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Why gay men risk HIV (abstract 27*)

• INSIGHT, qualitative case-control study by HPA– Compared 75 gay men who tested positive <2 yrs after

previous negative test with 159 who tested negative, also within two years of previous test

– 80% of cases had had URAI and 70% UIAI compared with 50% of controls any UAI

• HIV transmission within primary relationship– Partners who mistakenly thought both were HIV-– Partners in serodiscordant relationship – Partners where one person seroconverted during

rel’ship

• HIV transmission during casual sex– ‘Intentional’ (ego-syntonic) unprotected sex– ‘Unintentional’ (ego-dystonic) unprotected sex

*Elam G et al. Intentional and unintentional UAI among gay men who HIV test in the UK: qualitative results from an investigation into risk factors for seroconversion amongst gay men who HIV test (INSIGHT)

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HIV+ Caribbeans in London (abstract 25*)

• LIVITY study, five S London clinics– 206 HIV+ Caribbeans

• 62% born in Caribbean• 63% unmarried• 49% hetero, 33% gay, 8% bisexual, 10% did not define• Average lifetime partners 20 (cf HIV- STI clinic

attendees 10)– Gay men, 95. Straight men, 40. Straight women, 6.5

• 51% acquired HIV in UK, 26% in Caribbean, 23% elsewhere or not sure

– 36% recently had sex in Caribbean country, 25% had had sex with recent arrival from Caribbean

• Before diagnosis 25% ‘always’ used condoms, afterwards, 64%

• 40% lost to follow-up: distrust of research process and stigma

*Gerver S. Sexual behaviour among HIV positive black Caribbeans in south London: the LIVITY study

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And now the good news: treatment durability I (abstract 33*)

• Cohort survey of 3,647 patients in 27 clinics†

– ‘Treatment failure’ = any change made to class of therapy (not necessarily due to VL failure) or any intensification

– Only 15% in study failed– Median time to treatment failure = 7.3 years!– First-line HAART 51% NNRTIs, 26% PIs, 4% DPIs, 19%

other– 1/3 less likely to fail if started HAART @ CD4 >200– Nearly twice as likely to fail if did not start HAART

with AIDS– Ave cost of treatment from start of first line therapy =

£112,138

– †National Prospective Monitoring System-HIV Health Economics Collaboration

*Mandalia S. Cause and time to treatment failure of HAART and cost of care in NPMS-HHC clinics, 1996-2002

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And now the good news: treatment durability II (abstract 9*)

• 10,243 patients from UK-CHIC (UK Collaborative HIV Cohort)

– Counted entire time virally suppressed (VL<50) and related it to number of previous regimens

• Relative Risk of failure by number of previous regimens:

– 0 = 1 1 = 1.83 2 = 2.28– 3 = 2.65 4 = 2.68 5 = 4.10

• BUT if you manage to stay suppressed first year, your risk of subsequent failure falls to the same level regardless of number of previous regimens

– Except if on first regimen: even then, if you stay suppressed for 2 years, success rate approaches that of people on first regimen, regardless of number of previous regimens

*Benzie A et al. Viral rebound in patients on antiretroviral therapy with extent of previous failure and time with viral suppression

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Virological rebound rates (95% CI) per 100 p-yrs

0

10

20

30

40

50

≤1 yrs 1 - 2 yrs 2 - 3 yrs 3 - 4 yrs ≥ 4 yrs

Duration of viral suppression to ≤ 50 copies/mL

Vir

al

reb

ou

nd

ra

te p

er

10

0 p

-yrs

Number of previous regimens failed

0 1 3 ≥ 42

Benzie A et al. Viral rebound in patients on antiretroviral therapy with extent of previous failure and time with viral suppression. !2 BHIVA Conference, Abstract 9. 2006.

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And now the good news III• Comments from Caroline Sabin in Gilead satellite:

– Last year half of all patients on treatment were on the therapy combination they started with, and two-thirds on their first or

second one.

– 83% of patients starting HAART treatment-naïve and with >200 CD4 cells were on 1st or second regimen, <5% on 4th+ regimen

– About a 33% of patients did change their therapy.

– However only 13% changed due to the failure of therapy; the other 20% changed due to drug side effects without becoming

virally detectable.

– The proportion of patients with MDR-HIV on treatment has gone down. In 2000 one in six patients on treatment had

resistance to all three main classes of drugs; last year less than one in 10.

– Comment from Anton Pozniak: “It’s really not about treatment failure now, it’s about adherence and lifestyle issues.”