1. www.guscairns.com BHIVA 2006 Gus Cairns

2. www.guscairns.com 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

3. www.guscairns.com 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.

4. www.guscairns.com 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

5. www.guscairns.com 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?

6. www.guscairns.com 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%

7. www.guscairns.com 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

8. www.guscairns.com 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?

9. www.guscairns.com 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)

10. www.guscairns.com 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

11. www.guscairns.com 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

12. www.guscairns.com 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 = 11 = 1.832 = 2.28 –3 = 2.654 = 2.685 = 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

13. www.guscairns.com Virological rebound rates (95% CI) per 100 p-yrs 0 10 20 30 40 50 ≤1 yrs1 - 2 yrs2 - 3 yrs3 - 4 yrs≥ 4 yrs Duration of viral suppression to ≤ 50 copies/mL Viral rebound rate per 100 p-yrs Number of previous regimens failed 0 1 3 ≥ 4 2 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.

14. www.guscairns.com 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.”