The 18th European AIDS Conference (EACS 2021) brought together clinicians, researchers and people living with HIV to share and discuss some of the latest developments in the treatment and management of HIV, viral hepatitis, tuberculosis and COVID-19 from around the globe.
The impact of COVID-19 on HIV management
As with all other therapy areas, the COVID-19 pandemic has had a significant effect on access to health services for people living with HIV (PLWH) at all stages, from prevention to diagnosis to treatment. Compared with 2019, in 2020 there was a decrease of approximately 70% in the number of pre-exposure prophylaxis (PrEP) initiations of HIV treatment and the UK Health Security Agency reported that diagnoses of HIV decreased by 30%. The risk of death from COVID-19 for PLWH was low, but twice as high as the general population and almost all deaths occurred in people with comorbidities associated with COVID-19 pathology.
Insights from HIV vaccine research were useful to COVID-19 vaccine development
During discussions about COVID-19 vaccines, it was emphasized that the unprecedented funding allocated to their development, predominantly by governments, was the major factor in how quickly they have been made available to the public. In addition, discoveries from earlier vaccine development programmes, including HIV vaccine research, also accelerated the progress of effective COVID-19 vaccine development.
In turn, it is hoped that the new mRNA vaccine technologies that have been used to develop COVID-19 vaccines may be helpful in HIV vaccine development. However, it is important not to underestimate the complexity of HIV compared with the virus that causes COVID-19 and the gulf in funding between the two vaccine programmes.
Equity, diversity and inclusion in HIV clinical trials
One of the key messages shared at EACS 2021, which was held during Global Diversity Awareness Month, was the recognition of the long-term lack of representation of a wide range of PLWH in clinical trials. Generally, white men are the overwhelming majority of trial participants and this has been the case since the beginning of HIV clinical trial research in the 1980s.
In one of the sessions discussing this issue, the findings of a recent systematic review show that there continue to be large data gaps in research that limit the understanding of comorbid diseases in women. Research that did include women living with HIV showed that they are at a higher risk of cardiac disease, kidney disease, lower bone mineral density and poorer cognitive function than women in the general population. The lack of research that includes women of all ages living with HIV contributes to the difficulties determining if these increased risks are biological or due to other factors, such as socioeconomic status or ethnicity.
There is also a lack of inclusion for other groups in clinical trials, such as people of different ethnicities, transgender people and people with comorbidities. Consequently, the impact of treatment on these groups of people is poorly understood by researchers, clinicians and other healthcare providers (HCPs).
There are some initiatives to increase the amount of research in women living with HIV, who represent 50% of PLWH and 35% of new diagnoses, that are ongoing. However, the effectiveness of treatment, healthcare and the understanding of the impact of health inequalities will remain a question if such initiatives remain the exception rather than the rule. There is therefore an urgent need to increase the representation of women and other groups of people living with HIV in clinical trials, and to increase the awareness of the challenges the groups face among HCPs to ensure equitable healthcare for all PLWH.
Reducing the burden of HIV treatment
EACS 2021 presented several advances in the field that aim to reduce the burden of the disease by minimizing the frequency of drug administration. For example, presenters showed evidence that PrEP may be used on-demand instead of daily, and that newly developed long-acting treatments can be given as an injection as infrequently as once every 6 months. Such modifications to HIV management could significantly decrease the burden of disease and treatment. The UK’s National Institute for Health and Care Excellence has recently approved long-acting cabotegravir plus long-acting rilpivirine for the treatment of people who are already taking treatment regularly and have reached an undetectable viral load. This is a major breakthrough and revolution in the treatment of HIV, changing the requirement for daily pill taking to an injection once every 2 months. This, coupled with the knowledge that PLWH who have an undetectable viral load cannot pass on HIV (Undetectable=Untransmissible, or U=U) will contribute to the reduction of new cases and the long-term goal of ending the HIV epidemic.
The power of patient advocacy
During the conference there were numerous sessions on the developments in HIV prevention and treatment. These highlighted the ongoing progress achieved since the emergence of HIV in the 1980s and the first complex triple therapy treatments becoming available in the 1990s to PLWH in the global North. The activism of PLWH contributed to the development of treatments and specialist healthcare over the following decades, with the welcome step of PrEP being approved by the US Food and Drug Administration in 2012 and available in England from 2020.
It is important to remember that access to HIV prevention measures and treatment has never been uniform globally, despite international collaboration and specialist funding mechanisms such the Global Fund and the US President’s Emergency Plan for AIDS Relief. Lack of access remains a deadly issue for many people living in low- and middle-income countries, such as those in Eastern Europe, parts of Africa and Asia. This is mainly due to pharmaceutical patents, the high price of medicines and accessing healthcare. Additionally, widespread stigma linked to the disease still plays a large role in diagnosing HIV and the treatment of PLWH in all settings.
The immense progress that has been made in HIV treatment in the past 40 years shows what can be achieved when patients are empowered and given the opportunity to self-advocate and work with stakeholders, and the importance of listening to patients for pharmaceutical companies, governments and researchers.
We would like to thank Esther Dixon-Williams for co-authoring this article.
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