Furore over Nigeria AIDS survey

*Monthly HIV injection could free patients from gruelling drug regimen
*High rate of viral suppression among people new to care but gaps remain
The results of the first national Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) survey would be announced today in Abuja by President Muhammadu Buhari. The goal of the Nigeria AIDS Indicator and Impact Survey (NAIIS) was to examine the distribution of HIV disease in Nigeria, to assess the coverage and impact of HIV services on the population level, and to measure HIV-related risk behaviors using a nationally representative sample.

The survey will provide programme managers and policy makers with a more detailed and specific understanding of the HIV epidemic in the country in order to guide scale up of treatment and prevention services across all age groups.The Government of Nigeria represented by the National Agency for the Control of AIDS (NACA) and the Federal Ministry of Health (FMoH) in conjunction with key stakeholders in Nigeria’s HIV/AID response including the United States President’s Emergency Preparedness Fund for AIDS Relief (PEPFAR), the Global Fund and Implementing Partners in December 2018 concluded data collection for NAIIS in all the 36 States and the Federal Capital Territory (FCT) Abuja.

Head Corporate Communications at NACA, Mrs. Toyin Aderigbigbe, told journalists on Monday: “Data analysis for the survey has been concluded and we are now at the verge of having the Presidential announcement of NAIIS results, by His Excellency, President Muhammadu Buhari.”

Meanwhile, according to results from twin trials that enrolled more than 1,000 people in 16 countries long-acting medicines have proved as effective as daily pills in preventing HIV from replicating.The drugs tested, cabotegravir and rilpivirine, are given once a month as an injection. They are the first of several long-acting antiretroviral HIV medicines in development, which researchers hope will tackle one of the toughest challenges in the fight against HIV: how to ensure that people consistently take the drugs that can prevent the virus from replicating in their cells. Skipped doses put people with HIV, and their sexual partners, at risk.

Researchers say long-acting medicines could ensure that the vast majority of people who are prescribed antiretroviral drugs — the standard treatment for HIV — successfully suppress the virus, in line with goals set by the United Nations (UN). And it could help the US government to meet its aim of reducing HIV transmission in the country by 90 per cent in the next decade. Researchers hope that long-acting drugs might prevent HIV, too.

“The combination is paradigm shifting,” said Chloe Orkin, an HIV researcher at Queen Mary University of London, who reported the trial findings on March 7, 2019, at the Conference on Retroviruses and Opportunistic Infections in Seattle, Washington. “Instead of being reminded that you have HIV 365 days a year, it’s reduced to just 12,” she said. “That gives people a kind of freedom.”

In the 1990s, researchers devised combinations of antiretroviral drugs that transformed HIV from a death sentence into a chronic condition kept in check by daily pills. But sticking to the daily pill schedule can prove tricky. Some people can’t easily reach clinics to get a regular supply of drugs, for instance — a problem that longer-lasting medications could ease.

The antiretroviral injections tested in the trials include a mixture of cabotegravir and rilpivirine, which each block HIV from replicating but in different ways. The medicines remain in the body’s tissues and leach out over weeks. ViiV Healthcare, a drug company in London that was spun off from pharmaceutical giants GlaxoSmithKline and Pfizer, developed the combination.

One of the clinical trials compared virus levels in blood samples from 556 people with HIV who had not previously taken antiretroviral drugs. For 11 months, participants took either monthly injections or daily doses of three common antiretroviral pills. The other trial had a similar design, but enrolled 616 people who had been taking the standard combination of antiretroviral pills for at least six months before the study started. Not only did the injections keep HIV in check as effectively as pills in both studies, but in each study more than 85 per cent of people on injections said they preferred the monthly regimen.

That does not surprise Orkin. Daily doses grow tiresome, especially for adolescents, she says — and become toxic, as people grow old. “Putting three drugs into your body every day for 40 years is a long cumulative exposure,” she said. Some drugs also interact badly with other medications that people might take as they age, such as treatments for high blood pressure. Orkin expects periodic injections of two HIV drugs to take less of a toll than a daily three-drug dose.

ViiV and other groups are now conducting trials to see whether cabotegravir or rilpivirine injections can prevent HIV transmission. Preventive therapy using existing antiretrovirals, called pre-exposure prophylaxis (PrEP), is effective — but it can be a hard sell for people without HIV who don’t like the side effects, stigma or burden of the daily pills. Many HIV researchers hope that the development of long-acting injectable drugs could increase adherence to PrEP.

And scientists is still searching for a cure for HIV infection. A study published in Nature on March 5, 2019, reports that a person with HIV seems to be clear of the virus after receiving a stem-cell transplant that replaced their white blood cells with those from a person with natural resistance to the virus. This is only the second time that this method has been shown to remove all traces of the virus from a person.

Meanwhile, researchers have recorded high rate of viral suppression among people new to HIV care but gaps remain.Eighty-six percent of individuals who entered HIV care soon after diagnosis maintained viral suppression after 48 weeks during a clinical trial conducted at four National Institutes of Health (NIH)-funded Centers for AIDS Research (CFARs) across the United States. Participants in the clinical trial, called iENGAGE, achieved viral suppression in an average of just 63 days. The findings were presented in a poster at the Conference on Retroviruses and Opportunistic Infections (CROI 2019) in Seattle.

The findings from iENGAGE, which was funded by NIH’s National Institute of Allergy and Infectious Diseases (NIAID), underscore the benefits of linking people with HIV to treatment services soon after diagnosis and highlight the importance of efforts to engage all people with HIV in care. Provision of effective HIV treatment resulting in sustained viral suppression is a critical component of efforts to end the HIV epidemic in the United States.

Notably, many iENGAGE participants had other medical conditions and unmet basic needs that can make adherence to medical visits and daily antiretroviral therapy (ART) difficult. About half of the study participants reported needing supportive services, including assistance with housing, employment, food and transportation. Mental health issues were also prevalent, with 31 percent of participants having depression and 30 percent having anxiety. Roughly one-third of participants reported high-risk alcohol use, and 18 percent reported substance use.

The iENGAGE trial was conducted at clinical trial sites in Baltimore; Seattle; Birmingham, Alabama; and Chapel Hill, North Carolina, participating in the CFAR Network of Integrated Clinical Systems (CNICS). Ten years ago, these sites recorded an approximately 60 percent rate of viral suppression among people new to HIV care.

The iENGAGE trial was designed to evaluate a behavioral intervention aimed at educating people newly diagnosed with HIV and reinforcing the importance of adherence to care. The 371 participants were enrolled within 14 days of initiating HIV medical care and randomly assigned to receive the behavioral intervention plus standard care or standard care alone. The intervention, which combined two established approaches to enhance HIV medical visit adherence and ART adherence, comprised four in-person counseling sessions tailored to participants’ individual needs, as well as phone support, during the first 48 weeks of treatment.

The intervention did not appear to affect viral suppression after 48 weeks. The high overall rate of viral suppression and the short average time to achieving suppression did not differ between the two study arms.The iENGAGE investigators suggest that recent improvements in standard HIV care contributed to this overall high rate of viral suppression. These improvements include changes in HIV treatment guidelines to encourage early treatment for everyone diagnosed with HIV, an increased focus in clinical practice guidelines on retaining people in the HIV care continuum from diagnosis to viral suppression, and the inclusion of integrase inhibitors — a new potent and well-tolerated class of antiretroviral drugs — in first-line ART regimens. The researchers plan to assess viral suppression rates among iENGAGE participants at 96 weeks to evaluate whether the intervention improves long-term adherence to care.

The findings underscore the effectiveness of HIV care but also highlight the remaining challenges of closing treatment gaps by identifying strategies to engage and retain people with HIV in HIV treatment services. One potential approach could involve incorporating behavioral interventions into communities as part of rapid ART initiation programs, the iENGAGE investigators suggest.