New Developments in HIV Kerri Howley Coordinator – The Green Room

Current Victorian statistics  As of July ,500 Victorians are living with HIV  Over 60% aged between  Demographics of transmission largely unchanged  80% are taking medication for HIV  There has been a 50% improvement in immune function since

Changes to HIV treatment  Start earlier – 350 or above?  New drugs = 5 classes  New Ist line treatments = 1 to 2 tablets daily  Treatment is a life time commitment = no treatment breaks  HIV genotyping is a standard practice for all preparing to start and in those preparing to change medication

Babies and HIV - Chronic Viral Illness Program RWH  For all HIV positive partners – effective, timely & appropriate HIV treatment prior to insemination  For all men it involves separation of sperm from semen  For HIV positive men it involves sperm ‘washing’  For all couples it involves artificial insemination, fertility investigations, counseling, regular HIV testing prior, during and after insemination  Sperm washing reduces the risk of HIV transmission to less than 1in 2000 per treatment  Cost is incurred for the insemination only

Super infection of HIV  When a HIV positive person gets a second strain of HIV (i.e.. Genetically different from 1 st )  Rare: may cause re-occurance of HIV illness, may mean that treatment options are reduced, if 2 nd virus takes over & is resistant  Smith et al in 2004 – in HAART naïve newly diagnosed, 5% acquired 2 nd infection with in 6-12 months, ‘rare’ in those on HAART  2 viruses co-exist, it is not recombination  Risk is related to unprotected sex, and amount of activity in early and established phases of HIV disease  Screening; re-screen HIV genotype for all unexpected viral load increases  

HIV transmission risk issues  Swiss Study 2008 ‘ People who have been taking treatment for at least 6 months, take correct treatment, do not have STIs are never infectious to their monogamous heterosexual partner’  Fox et. al 2009 – a study of 30 sero-discordant (mostly gay) couples having unprotected sex for 2 or more years “A blanket healthcare message of safe sex seems inappropriate for all HIV sero-discordant couples,” comment the investigators, “provision of an open discussion of risk and identification of barriers to condom use may be more meaningful than promoting a 100% condom approach.”  Nicopoullous JDM et al.2009 –Sperm washing study 10% of men with undetectable viral loads had ‘significant’ amounts of virus in their semen

Anal cancer and HIV  3 rd most common malignancy in HIV  59 times more likely to be at risk than the rest of the community  1;1000 people with displasia will develop anal cancer  ;1000 will have displasia; significance unknown  Risks; smoking, immuno-deficiency, anal sex  Like cervical HPV 16 & 18 are more likely to be problematic.  Positive women 7% more at risk and at higher risk of cervical CA  Screening: 6/12 medical review for skin changes  Self-exam; digital examination to 2-3cm above sphincter for lumps  Partner inspection  Stop smoking  Logistics of a regular screening? 

HCV transmission and HIV positive MSM Increased risk of HCV transmission  HCV more likely to be found in semen of HIV +ve people?  Type of sexual activity implicated (group, trauma, sharing toys, frequency of anal sex)  Duration of sexual activity  Presence of STI  Drug use, route and effects (rectal –ulceration, duration effecting drugs increase risk of rectal injury)  Action; annual screening for all HIV +ve MSM, ask about sexual activity, and recreational drug use  Schmidt AJ et al. Risk factors for hepatitis C in HIV-positive MSM.A preliminary evaluation of a case control study. Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, abstract MOPEB037, Sydney 2007 

HIV and risks for co-morbidity  Aging  The drugs  Lifestyle risk factors  Genetic predisposition  The HIV virus – persistence of immunodeficiency, immuno- dysfunction, and heightened inflammatory response Deeks S Immunologic aging: Are antiretroviral treated patient aging too fast and if so why? Australasian HIV/AIDS Conference 2009 Brisbane Paper 38