Saskia Janssen

This session covered hot topics in several fields. Original studies and a case report were presented, subjects including ART-free remission, optimization of TB diagnosis and management of HIV-TB co-infection.

IMPAACT2008 was a randomized open-label trial assessing safety and early efficacy of the broadly neutralizing antibody VRC01 in infants initiating ART, in 3 African countries and Brazil. Adverse events were common but unrelated to VRC01. HIV viral load and DNA declines were similar among groups, potentially due to baseline ART/VRC01 resistance or low VRC01 trough levels. CASTLE is a randomized trial from Malawi among PLHIV admitted to hospital, investigating whether high-sensitivity urine lipoarabinomannan (LAM) and digital chest X-ray with computer aided diagnosis improves TB diagnosis and reduces mortality. Combined diagnostics led to increased TB diagnoses, but no difference was seen in mortality. Dr Dickter reported on an 63 yo patient living with HIV who remains in HIV-1 remission after allogenic stem cell transplantation because of acute myeloid leukemia. Seventeen months after interruption of ART there is no evidence of HIV-1 RNA rebound and no detectable HIV-1 DNA. A retrospective sub-goup analysis of the VISEND study in Zambia was presented among patients with high baseline viral load. Dolutegravir and recycled tenofovir + lamivudine was superior to protease inhibitor-based treatment using a new nucleoside backbone. Virologic failure was uncommon in the dolutegravir group (5.3% at 48 weeks), however associated with incident TB.

Studies reported here touch upon advances and challenges in the field of HIV cure/ART-free remission. Pharmacokinetics in infants remain challenging and the lack of efficacy in IMPAACT2008 may be cause by low trough levels of VRC01 that remain to be explained. However it is promising that the number of patients reported with ART-free remission are increasing. PLHIV admitted to hospital remain a sub-group with unacceptable high mortality and contributing factors need to be unraveled to improve their management. Dolutegravir-based ART is superior to classical second-line PI-based regimens, however implementation needs to be done cautiously with regard to incident TB.