IN THE LOOP

Studies on undetectability and PrEP were among the biggest stories coming out of the 2018 International AIDS Conference (AIDS 2018) held in July in Amsterdam, Netherlands. The latest data reinforce the efficacy of prevention tools now available to help curb the epidemic as well as the need to make these interventions available on a global scale. Below we highlight some of the most important studies presented at the conference. You can find more conference highlights here, including studies on new HIV treatment regimens, vaccines, and the search for a cure.

Researchers presented further evidence that a person living with HIV with an undetectable viral load has zero risk of transmitting the virus to their sexual partners. The PARTNER 2 study documented nearly 77,000 condomless sex acts between HIV serodiscordant (one partner positive, one negative) gay male couples where the HIV-positive partner had an undetectable viral load—the study found zero transmissions between these men. Although results from the first phase of this study were presented in 2014, the level of evidence was not quite as convincing for gay men as it was for heterosexuals. These findings confirm that U=U is true for all people living with HIV and underscore the importance of ensuring equitable access to treatment and other support services. Just over half of Californians living with HIV have achieved viral suppression, with Blacks and Latinos being less likely to be virally suppressed than their white counterparts.

A new study from Emory University showed that PrEP uptake was significantly associated with declines in new HIV diagnoses in states across the nation. Researchers looked at correlations between PrEP use and HIV diagnosis rates, using data from people aged 13 and older in all 50 states and Washington, DC, from 2012 and 2016. Results indicated that new HIV diagnoses decreased in states with the highest PrEP use and increased in states with the lowest PrEP use – even after controlling for state levels of viral suppression. While the rate of PrEP use in California is higher than most states, only a fraction of those who could benefit from the intervention are currently using it. Recent data indicate that PrEP uptake is lowest among Blacks, Latinos, women, and young people.

Another study, conducted in France, found that PrEP is highly effective at preventing HIV whether it’s taken daily or according to an “on-demand” protocol. Participants in the study were able to choose whether to follow an on-demand dosing schedule or to use daily dosing. On-demand dosing involves taking a double dose of PrEP (two pills) anywhere from 2 to 24 hours before anticipated sex, and then, if sex happens, one tablet at 24 and 48 hours after the double dose. If sex occurs several days in a row, one pill should be taken each day until 48 hours after the last sexual encounter. None of the over 1,600 participants in the French study contracted HIV, leading the researchers to conclude that on-demand PrEP is an effective HIV prevention option. It is important to note that the majority of participants in this study (99%) were gay and bisexual men. Additional research is needed to examine the efficacy of on-demand PrEP among women, heterosexual men, and transgender individuals. Although daily dosing is still recommended by the CDC for PrEP users in the United States, the International Antiviral Society-USA recently recommended on-demand PrEP as an alternative for gay and bisexual men who have sex less frequently. On-demand dosing is also supported by guidelines of the European AIDS Clinical Society as well as the national bodies in the United Kingdom, France, Canada, and Australia.

Using PrEP does not lower levels of feminizing hormones, according to another study presented at the conference. The iFACT study enrolled 20 HIV-negative transgender women to examine potential drug-drug interactions between feminizing hormone therapy and PrEP. The study concluded that concurrent use of hormone therapy and PrEP did not affect hormone levels. While the study also found that feminizing hormones had a small impact on the level of PrEP medication in the blood, the level was still within the range that several studies have shown to be highly protective.

Nearly two dozen of the world’s leading scientists published a consensus statement on the use of HIV science in the criminal justice system. The statement includes a detailed analysis of the most recent scientific data on HIV transmission and recommends that “more caution be exercised when considering criminal prosecution” of people living with HIV. The statement is considered a milestone in the worldwide movement to modernize outdated HIV criminal laws. In 2017, California passed legislation to reform several laws that unfairly criminalized and stigmatized people living with HIV.

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