Cure Research narrative. Enjoy!

Cure Research at IAS 2013

July 19, 2013, by Liz Highleyman

Cure research has been a mainstay of recent HIV/AIDS conferences, and the International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention this month in Kuala Lumpur was no exception. While researchers presented some promising findings, the overall emphasis was on how far we are from practical and widely applicable approaches to a cure.

HIV REMISSION

The headline-grabbing news was a report by Timothy Henrich from Brigham and Women’s Hospital revealing that two Boston men who received bone marrow stem cell transplants to treat lymphoma had no detectable HIV at seven and 15 weeks after stopping antiretroviral therapy, or ART (abstract WELBA05).
Unlike the Berlin Patient, the Boston men did not receive stem cells from a donor with genetically resistant immune cells carrying the CCR5-delta-32 mutation, meaning they lack one of the receptors HIV uses to enter cells. The men did, however, undergo a milder pre-transplant chemotherapy regimen that enabled them to stay on ART. Once they had no signs of HIV for six months, they started an experimental treatment interruption. So far, HIV genetic material has not been detected using the most sensitive tests.
Although viral rebound typically happens within two to four weeks after ART interruption, according to lead investigator Daniel Kuritzkes, it is too soon to say these men are cured. “The virus could come back next week, after a few months, or even after a year,” Henrich told reporters.
More recently, a sobering report underlined the risk of stem cell transplantation. Hoping to replicate the Berlin Patient approach, researchers at the University of Minnesota in April performed a transplant of cord blood (which contains stem cells) from a donor with the CCR5-delta-32 mutation, in an attempt to cure an HIV-positive boy with leukemia.
Unfortunately, the university announced this week that the boy, 12-year-old Eric Blue, died in early July after developing severe graft-versus-host disease, a common complication of stem cell transplantation. Cases such as this demonstrate why stem cell transplants will not be appropriate for broad application as an HIV cure.

EARLY ART FOR INFANTS

Deborah Persaud (photo: Jan Brittenson)

Researchers are also working to replicate the success of a Mississippi baby first presentedby Deborah Persaud from Johns Hopkins at this year’s Retrovirus conference. The child, whose mother did not receive drugs to prevent perinatal infection, was started on combination ART within about 30 hours after birth but was later taken off treatment by her caretakers. At a “Towards an HIV Cure” symposium prior to the IAS meeting, Persaud gave an update that the child still has no detectable virus after 15 months of follow-up off treatment.
The International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) group will screen infants at more than 70 sites worldwide, looking for 20 to 30 HIV-infected babies whose mothers did not receive preventive drugs or did not achieve viral suppression during pregnancy. These infants will receive a full ART regimen within 48 hours after birth, and if they show no evidence of HIV antibodies after three years on treatment, they will interrupt ART to see if they can naturally maintain viral suppression.

ROUTING RESERVOIRS

German researchers reported another case of prolonged control of HIV replication after interrupting early treatment (abstract TUPE246). This 67-year-old individual is thought to have become infected in 1999 and started triple ART within one month of seroconversion, after an acute viral illness.
After maintaining stable undetectable viral load—except for two “blips”—and a high CD4 cell count, the man elected to undergo treatment interruption in 2004. He experienced a small viral rebound, remaining below 100 copies/mL, but soon regained control of viral replication and has been undetectable ever since.
In addition to having plasma HIV RNA below the limit of detection, the man has no evidence of HIV in his cerebrospinal fluid or gut tissue, nor HIV DNA in peripheral blood mononuclear cells (PBMCs). He shows strong anti-HIV CD4 and CD8 cell responses and a normal distribution of various types of T-cells. However, virus was recovered from his CD4 cells in the laboratory using a humanized mouse model, indicating the presence of residual replication-competent HIV.
The German case joins those of 14 French patients treated during early infection, known as the VISCONTI cohort. Experts expect more such cases will come to light thanks to increased awareness of the possibility.

Antoine Cheret (photo: Liz Highleyman)

Antoine Chéret and fellow investigators with the French OPTIPRIM study are looking at 90 people randomly assigned to start standard three-drug ART or an intensive five-drug regimen during primary HIV infection (abstract WEAB0101). After 12 months on treatment, almost all achieved undetectable plasma HIV RNA as well as decreased HIV DNA in PBMCs, indicating a reduced viral reservoir in resting T-cells. After 24 months participants will interrupt treatment to see if they can maintain viral control like the VISCONTI patients.
Most people are not diagnosed with HIV during primary infection, but even during chronic infection, those who start treatment sooner with CD4 counts above 500 are more likely to see a reduction in their reservoir of infected cells, potentially making them better candidates for an eventual functional cure.
Laurent Houqueloux from Orléans Hospital reported that people who started ART with more than 500 cells/mm³ had reduced levels of integrated HIV DNA in PBMCs and were many times more likely to experience immune function normalization compared with those who started treatment later (abstract WEAB0102).
The Berlin Patient, the Boston stem cell patients, the German case, and the Mississippi child indicate that some individuals, under special circumstances, can achieve a functional cure that allows them to remain off treatment without disease progression for a prolonged period.
But while these examples “are exciting and give hope to patients and scientists that a cure is possible, the challenge is to understand the mechanism by which these cures have happened,” said Sharon Lewin of Monash University at an IAS press conference. “Thirty-three million people have established reservoirs, and the goal is to find out how to let them go off treatment.”
The full IAS 2013 program is available online. 
Liz Highleyman (liz (at) hivandhepatitis.com) is a freelance medical writer and editor-in-chief of HIVandHepatitis.com.

There is a rationale with moving forward with clinical trials. Enjoy this article!

Setbacks and Progress in the Search for an HIV Cure

July 22, 2014, by Liz Highleyman

Françoise Barré-Sinnousi, Sharon Lewin, and Deborah Persaud (photo: Liz Highleyman)

The quest for a cure for HIV has been one of the themes at the 20th International AIDS Conference (AIDS 2014) taking place this week in Melbourne, with scientists reporting both advances and setbacks.
Jintanat Ananworanich, formerly of the Thai Red Cross and now with the U.S. Military HIV Research Program, gave an overview of “Where Are We Now and Where Are We Going?” with cure research at an opening plenary on Monday.
After reviewing some special cases that offer proof-of-concept that it may be possible to control HIV at least temporarily without antiretroviral therapy (ART)—including the Berlin Patient, the Boston Patients, and the Mississippi Baby—she concluded that success will likely require a combination approach, for example, early ART, agents that overcome viral latency, gene therapy to protect CD4 cells from infection, and therapies that strengthen immune response.
Researchers also discussed cure-related work in oral abstract sessions at the main conference and at a two-day pre-conference “Towards an HIV Cure” symposiumorganized by the International AIDS Society (IAS). Several of them summarized their findings and offered their thoughts about future directions at an IAS press briefing on Monday.
Deborah Persaud from Johns Hopkins gave an update on the Mississippi Baby (now a child nearly four years old) who just before the conference was found to still have HIV after having no detectable virus while off ART for more than two years. This case suggests that HIV establishes latent reservoirs very early—the child started treatment just 30 hours after birth—and even a few remaining infected cells are enough to rekindle viral replication.
Though disappointing for the child, who has resumed antiretroviral treatment and is in good health, Persaud said, “we have learned a lot from this case and it provides a strong rationale for moving forward with a clinical trial” of very early combination therapy for infants.
Dan Barouch from Beth Israel Deaconess Medical Center described a study in monkeys,published this week in Nature, showing that an HIV-like virus seeds itself in cell and tissue reservoirs very soon after sexual exposure—even before viral load is detectable in blood plasma. Very early ART reduced the size of the reservoir, but did not prevent re-emergence of the virus after treatment was stopped. “Even very early is not early enough,” he said.
One challenge in the cure field raised by Ananworanich is that scientists—not to mention regulatory authorities, pharmaceutical companies, and HIV-positive people themselves—do not all agree about the definition of a cure. Experts increasingly agree that complete eradication of every last bit of virus may not be possible, but many people living with HIV would be happy to be able to maintain control of the virus for prolonged periods off ART.
“We’re looking at the moment at achieving long-term remission, and how long can we go [without antiretrovirals],” said AIDS 2014 co-chair Sharon Lewin from Monash University. “We’ve realized in the past year that the virus can really hang around for a very long time and pop up unexpectedly.”
One widely used strategy in HIV cure research is dubbed “kick and kill” or “shock and kill.” This involves using various methods to reactivate latent viral genetic material in resting T-cells. Once this virus “wakes up” and starts replicating, it becomes visible to the immune system and susceptible to antiretroviral drugs.
One type of agent used to reactive latent HIV is histone deacetylase (HDAC) inhibitors. HDACs are enzymes that keep DNA tightly coiled in a cell’s nucleus so it cannot be used to produce new proteins. HDAC inhibitors reverse the process, allowing viral gene expression and production of new virus.

Ole Schmeltz Søgaard (photo: Liz Highleyman)

Ole Schmeltz Søgaard from Aarhus University Hospital in Denmark described his team’s research using the HDAC inhibitor romidepsin, which is used as a treatment for lymphoma, to kick cells containing dormant HIV out of their resting state.
In a small study of six patients with long-term viral suppression on ART, romidepsin was shown to increase histone acetylation in lymphocytes, raise levels of cell-associated HIV RNA in CD4 cells, and increase plasma viral load. However, the size of the viral reservoir—as indicated by total HIV DNA in CD4 cells—did not change significantly.
“We have enough data to say the agent was successful in doing what it was supposed to: kicking virus out of cells,” Søgaard said. “We can make cells release virus into plasma, but that may not be enough to reduce the reservoir.”
Steven Deeks from the University of California at San Francisco said this first evidence that we can identify latent HIV and shock it out of hiding in people “is the single most important advance of this meeting.” That’s the shock, he said, “but once [the virus] gets out, we have to kill it.”
Like Ananworanich and most others working on HIV cure research, Deeks thinks a combination approach will be required to achieve a functional cure that allows people with HIV to remain off ART without disease progression. As the virus is released from newly activated resting cells, the immune system will need to be able to recognize and attack it.

Steven Deeks (photo: Liz Highleyman)

“The Mississippi and Boston cases make me wonder if we will ever get rid of the entire reservoir,” Deeks said. “We may get rid of big chunk of it…but we need a way to control what’s left.”
Deeks predicted that the cure field will move in the direction of therapeutic vaccines or other immune-based therapies that can be used in combination approaches. Søgaard’s team has just started a new study looking at romidepsin in combination with the therapeutic Vacc-4x vaccine.
“We should not oppose vaccine and cure research, and probably we will need both,” predicted IAS President Françoise Barré-Sinoussi.
Liz Highleyman (liz (at) hivandhepatitis.com) is a freelance medical writer and editor-in-chief of HIVandHepatitis.com.

Multiple sex partners with or without protection against HIV? A Sero-typing related Stigma Issue???

Promiscuous Gay Nerd: Choosing to Love Poz Guys

September 26, 2014, by Jake Sobo

I met James¹ on Grindr. Well, not exactly – he was a friend of a friend, who also happened to be a fan of my writing. We had connected years ago and intended to meet up, but we never found the time. So when James pinged me on Grindr, my interest was piqued. He was gorgeous, successful, and hung like a fucking horse. I thought to myself, “okay, what’s the catch?” We made plans to spend a weekend in his hometown, a two hour drive from me.
But before I got in my car and made the schlep over to see him, he texted me to say that he had something to tell me. Something I should know before we met. At this point, most gay men I know would be preparing to run for the hills. Having a Grindr trick tell you before you ever meet that there’s something you ought to know, without just spitting it out, is usually a code red situation. But I wasn’t most gay men. Quite the contrary: Rather than feeling anxious or ominously worried, I put my hands together like a skinny girl at McDonald’s and prayed, “Please let him say that he’s positive.”
To say that this is a new perspective for me is an understatement. Nearly two years ago, just a few weeks after I started taking Truvada daily for PrEP, I penned an article on “Learning to Fuck With Poz Guys.” In that piece, I talked openly about the challenges I experienced incorporating HIV-positive guys into my (mostly condomless) sex life. The writing on the wall was pretty clear then that sexual transmission is nearly impossible with guys who are on treatment, have undetectable viral loads, and do not have an STI co-infection. Despite that growing scientific consensus, I still struggled with my own irrational fears and deeply-ingrained stigmatizing views of HIV-positive men. Like most gay men, I had been trained to avoid HIV-positive guys at all cost. Sure, you could use condoms. But why risk it?
We know even more today than we did in 2012. The preliminary results from the PARTNER study released in March this year firmly planted the jaws of many in the field squarely on the floor. If you’re not familiar with the ongoing clinical trial tracking serodiscordant couples that don’t use condoms consistently, let me briefly rehash its findings thus far.  In two years, not one person with an undetectable viral load –gay or straight – had transmitted HIV to their primary partner, during an estimated 16,400 occasions of sex among gay men and 28,000 among straight couples.
The kicker for HIV-negative folks like me on PrEP: none of the HIV-negative partners in the PARTNER trial are on PrEP (or PEP, for that matter).
But all this science aside, why in the world would I pray for my new beau to be HIV-positive? Knowing that there’s no risk of infection is one thing. But to actually seek out and desire HIV-positive partners is quite another.
The answer, I think, lies in the spectacular failure of my last relationship.
Like so many gay couples, Tim and I fought tirelessly over monogamy. We were both sluts who clearly loved to spread our seed. I didn’t mind the idea of him having sex with other guys, but he was controlling and jealous. He ominously threatened one day that if I ever cheated on him, he would beat the shit out of me. I nervously laughed it off. He couldn’t be serious? Right?
When we finally did open the relationship, he insisted on all sorts of restrictions. It turns out those restrictions were only for me. No sex in our house, he said. I’d come home from work and find evidence to the contrary. I didn’t really care. But the real stickler was his insistence that we use condoms whenever we fucked outside the relationship. As the bottom in the relationship, my getting fucked condomless would threaten both his dominance over me and his HIV-negative status.
So when I found out he bred a friend of a friend in the woods outside a party while I was inside with friends, I was done. A few weeks later, when he went out to the bar with friends, I enacted my own form of resistance: I went out and got my ass creamed. It felt exhilarating – liberating, even.
When I came home, he was drunk and furious. Somehow, he seemed to know what I had done. I denied it. But as I walked up the steps to our apartment, he took his first swing – the beginning of a long night that ended with his arrest.

∞

Throughout the entire relationship, HIV provided the rationale for Tim’s controlling jealousy in our open relationship. I’m under no illusion that this explanation is entirely legitimate; clearly, Tim had his own demons and insecurities that he desperately needed to deal with. Nonetheless, it was always lurking in the shadows of our relationship, providing a kind of scientific legitimacy to his control.
Tim’s behavior is an extreme example of what is a pretty common phenomenon for gay men I know. The fear of HIV leads gay men to all sorts of irrationalities. This is especially true for HIV-negative gay men, whose knowledge of the disease is largely fed by stigma and misinformation. When I came out to my parents at the age of 14, my parent’s first response was that I would probably die of AIDS. The LGBT youth group I attended regularly for the next two years didn’t teach me gay history; it taught me how to use a condom. Irregularities in the blood tests I needed to start Accutane in high school compelled my doctor to warn me that I might be HIV-positive. If a condom broke with a partner, I would get tested every month for the next six months – each time reading into some minute detail (the counselor’s tone of voice; his delay in returning to the testing room; an ominous voicemail)convinced that I was positive.
For most of my life, HIV was a specter haunting me and my sex life. Over time, I found ways to cope and manage the stress and risk that comes with being a promiscuous HIV-negative gay man. Perhaps the most significant step in that journey was educating myself about the actual risk of transmission, something that most gay men still don’t know enough about. If you asked a 21-year old Jake Sobo what the chances are of getting HIV after being fucked by a poz guy without a condom, I probably would have said 50%. It’s actually less than 2%, on average. And as we know now, treatment and/or PrEP virtually eliminates that risk altogether.
Getting older as a gay man almost always means that some of your friends will test positive at some point. While as many as one in four gay men overall are HIV-positive in some urban areas, that percentage jumps to over 40 percent for guys in their 40s. It sounds trite, but being friends with HIV-positive guys and realizing that their lives were basically no different from my own played a significant role in helping me reshape my understanding of the disease.
What PrEP has done for me cannot be understated. I no longer live in a world where contracting HIV seems a possible outcome that warrants my anxiety or stress. With PrEP, I can have the sex that I want, with whomever I want, without HIV looming over my decisions.
As I picked up the pieces after my last breakup, I resolved to never be in a relationship again in which I didn’t see eye-to-eye with my partner about non-monogamy and HIV risk. I’m just not built for sex with one person, and I don’t ever want to be in a situation where HIV provides the grounds for controlling my behavior. But finding another gay man as liberated from the fear of HIV seems daunting – especially living in a non-urban area. I used to think that I might never date seriously again.
But, as luck would have it, it turns out guys on PrEP aren’t the only ones who don’t fret about contracting HIV anymore.

∞

Three dots moved silently on my iPhone screen, indicating an impending message. Finally, after what seemed like an eternity, James’ message came through. My prayer was answered.
Of course, James is a lot of things other than being HIV-positive. His serostatus turns out to be only one of so many things that I love about him. He’s goofy and ambitious. And, like me, he is a whore. We practice compersion, not jealousy; when I get my ass creamed by another guy, he doesn’t get angry. He gets turned on.
But I don’t love him despite his status, as many guys might imagine. It is not a glitch or problem or downside.  I love him, in part, because of it.
To guys out there who still don’t understand how this is possible, I invite you to look around you. The serodivide is crumbling. Hookup sites that used to allow only two options for HIVstatus now offer endless choices, from undetectable to on PrEP. Recent life expectancy projections suggest that gay men who test HIV-positive today and start treatment quickly will live longer than those who do not. Statistically speaking, my positive boyfriend is likely to outlive me.
While some friends of mine give guys who blithely refuse to fuck poz guys a pass, I don’t. You cannot hide your prejudice under the veil of risk anymore. That ship has sailed.
I know it’s not easy. Unlearning decades of stigma and fear will not happen overnight. It will take time and learning. That’s okay. But the cost of staying in place is too great, both for poz guys who face that stigma and fear on a daily basis, and to our communities which remain divided.
Tomorrow, September 27, is National Gay Men’s HIV/AIDS Awareness Day. If you’re an HIV-negative gay man and you serosort but want to do something to help end HIV stigma, take a first step. Stop serosorting. Fuck a poz guy.
Who knows, he just might be the man of your life.

¹ Names have been changed.
Jake Sobo is a pen name used for anonymity. Jake has worked in the world of HIV prevention for nearly a decade. He previously published a 19-part series documenting his experiences on pre-exposure prophylaxis (PrEP), “My Life on PrEP,” for Positive Frontiersmagazine, which was picked up by Manhunt, translated into French, and widely read in the HIV prevention world. He has spent the better part of his adult life having as much sex as possible while trying to avoid contracting HIV.

The beer belly issues among people on ART. A physical Stigma Issue??

Abdominal Body Fat Gains on ART and Viral Load: It Matters Where You Start

March 3, 2015, by Emily Newman

BETA reported from last week’s 2015 Conference on Retroviruses and Opportunistic Infections in Seattle.
New research presented at CROI 2015 last week gave new insight about a puzzling aspect of antiretroviral therapy (ART): lipodystrophy, or changes in body fat distribution. New findings show that people with higher viral loads when starting ART for the first time are more likely to undergo substantial body composition changes, such as an increased amount of fat in the abdominal area (called “central adiposity”), than those who start treatment with a lower viral load (abstract 140). This finding presents another reason why it’s important to start HIV treatment early.
Though it’s unclear why people on ART get lipodystrophy, protease inhibitors have, in the past, been suspected of causing body fat changes. Grace McComsey, MD, from Case Western Reserve University, presented new evidence that HIV, viral load and inflammation may also play a role in body composition changes above and beyond that which may be caused by any specific drug regimen.
In her study, treatment-naïve people with HIV who had viral loads in the highest range (over 100,000 copies/mL) before starting treatment had greater gains in abdominal fat and peripheral fat (e.g., fat on arms and legs) than people starting treatment with lower viral loads. People with higher IL-6 (a marker of immune activation) before starting treatment also had greater gains in peripheral fat.
A total of 328 people with no prior ART experience took part in the randomized controlled study, and were followed for a total of 96 weeks. Most (90%) of the participants were men, and the median age of study participants was 36. They were assigned to take tenofovir/emtricitabine (Truvada) plus one of the following combinations: 1) the protease inhibitor atazanavir and ritonavir (Reyataz and Norvir); 2) the protease inhibitor darunavir and ritonavir (Prezista and Norvir); or 3) the integrase inhibitor raltegravir (Isentress).
The researchers hypothesized that different medications would have different effects on fat gain. That’s not what they saw, however.
Using a body composition X-ray scan called DEXA, the research team found that men across all three study groups gained limb fat over the course of the study—with no differences based on the medication participants in each group were taking. Average increases per group ranged between 11% and 20%. Men also increased their abdominal fat by an average of 16% to 29% during the study—again, with no significant differences between medication groups.
Body mass increased during the study, with gains in all three study groups ranging from 3% to 3.5%.
In a question and answer session after her talk, McComsey showed concern about their findings, saying, “A 30% gain in fat after two years—that’s really bad. That’s a relatively short duration of treatment.”
Because there were no differences that seemed to be associated with the type of ART regimen, the researchers looked back to see if any of the factors they measured at baseline might be related to their findings. That’s when they realized, according to to McComsey, that viral loads prior to starting ART had an effect on later fat gain.
“Regardless of the treatment regimen, people who started at the high viral load strata gained double or triple the amount of fat than people who started at the lower viral load strata,” explained McComsey. Their findings provide another reason why it’s important to start HIV medications soon after diagnosis, and not wait until viral loads are elevated or CD4 counts are low.
The fat gains seen in the study may not necessarily be a negative consequence for people with high viral loads when they begin ART. McComsey said that the people in their study with higher viral loads prior to initiating ART, “may be sicker, in a way,” than people with lower viral loads, and that a greater gain in fat  seen during ART may mark a “return to health.”

Plan for being and staying "undetectable" or "negative." There are discipline issues! Enjoy article!

Ask a Pharmacist: The Journey to “Undetectable”

November 21, 2013, by Jennifer Cocohoba, PharmD, AAHIVE

When a person living with HIV, together with his or her clinician, decides it is the right time to start antiretroviral therapy (ART), one major goal is usually to “get to undetectable“—that is, to suppress viral replication so that very low levels of virus remain.
And today, that goal is more attainable than ever. “With the currently available potent HIV regimens, I don’t see why we can’t achieve close to 100% of patients reaching undetectable viral loads,” says Chris Nguyen, an HIV pharmacist with Walgreens in San Francisco.
Read on to understand how undetectable viral load is reached, and for tried-and-true strategies and tips for keeping the virus in check.

MEASURING THE DESCENT

The journey to undetectable is similar to climbing down a steep mountainside to safer ground. Viral load is like a marker of your descent down the mountain, and antiretroviral therapy (ART) can be seen as a rope you use to climb down safely.
Within six weeks of starting ART, your clinician is looking for a sharp drop in your viral load, usually a 1-log drop. (Click here for a handy cheat sheet on “log” changes.) For example, on the logarithmic scale, a viral load of 100,000 copies/mL is equal to 5 log copies/mL. After six weeks, your clinician might check to see whether the viral load has decreased to approximately 4 log copies/mL (10,000 copies/mL), which represents a 1-log reduction. After 24 weeks, highly effective ART should result in an undetectable viral load.
Some people mistakenly think that being “undetectable” means that there is no HIV virus left in the body. This is not the case. “Undetectable” means that there is such a small quantity of virus circulating in the blood that none was seen in a particular blood sample.
One of two assays, either reverse transcriptase polymerase chain reaction (RT-PCR) or branched DNA (bDNA), is typically used to measure the amount of HIV-RNA (HIV’s genetic material), in a small sample of blood. Each assay gives a good estimate of the burden of virus in the body, but lab machinery is never perfect, and both the RT-PCR and bDNA have upper and lower limits to how well they represent virus levels. In addition, some cells contain dormant HIV that is not currently replicating but has the potential to do so. These cells make up the “latent HIV reservoir,” and RT-PCR and bDNA assays cannot measure the amount of virus they contain.
For these reasons, when you have an undetectable viral load, your count is not listed as “zero”; it may instead be listed as <75 copies/mL (for a bDNA test) or <20 copies/mL (for the most sensitive RT-PCR). There is some variation between the standard tests used to monitor viral load; clinicians typically aim for the ART regimen to suppress the virus to below 50 copies/mL.
Why do clinicians strive for undetectable? “Keeping an undetectable viral load allows your immune system to begin its recovery and means the virus will not develop resistance to your meds,” says Dr. Ruth Greenblatt, a physician at San Francisco General Hospital with more than 20 years of experience caring for people living with HIV and AIDS.

WHAT IT TAKES

Like climbing down a mountain, getting to undetectable takes some work, but it is possible with the right equipment. Suppressing HIV to undetectable levels depends on finding the right regimen—and sticking to it—to stop the virus from hijacking more of the body’s cells and making new copies of itself.
Adhering to an ART regimen is one of the foundations of HIV treatment, and it can take some getting used to. (See below for some strategies to boost adherence.) But today, as Dr. Nguyen points out, “many of the regimens are very well tolerated, which helps.” And the rewards are huge: “I remember one of my newly diagnosed patients coming in a month after starting his regimen, raving about how his viral load has drastically dropped in such a short amount of time, and how happy his provider was,” Dr. Nguyen recalls. “It brought a big grin to my face seeing how excited he was.”
Good adherence involves taking the right pills at the right time on a regular basis, to keep drug levels high enough to continually suppress HIV replication. When you interrupt your ART or miss doses, the levels of those HIV-fighting drugs decline—sometimes imperceptibly, sometimes quit a bit. When drug levels decline too far to keep the virus in check, HIV can resume replicating, and viral load rises.

The Adherence–Resistance–Viral Load Connection

Closely connected to low adherence is the possibility of drug resistance. To keep HIV in check, an ART regimen must include drugs from multiple drug classes that block replication at different stages in the viral lifecycle. When missed doses cause drug levels of one or more medications to fall and the virus replicates, the new copies may contain genetic mutations against those drugs, rendering them less effective or even ineffective and limiting future options for treatment.
Scientists and clinicians know that low adherence can lead to HIV drug resistance, but they are still trying to better understand the specifics. For example, many people living with HIV have long been advised to take at least 95% of their medicines each month. It is certainly true that adhering your regimen at least 95% of the time can help avoid resistance and keep your viral load undetectable. However, researchers are currently exploring whether lower levels of ART adherence may be possible without sacrificing viral suppression.
Dr. David Bangsberg’s studies in the San Francisco–based REACH cohort found that a group of people on non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens still had an undetectable viral load even though they were skipping 25%–50% of their doses. Other researchers are also beginning to recognize that different patterns of adherence (such as skipping on the weekends versus skipping more sporadically) may have different impacts on resistance and viral load. And another study found that participants who had been undetectable for twelve months prior to skipping doses had a 47% lower risk of virologic failure (that is, failure of the drugs to keep the virus suppressed) compared with those who had been undetectable for only one month before reducing their adherence.
That said, the jury is still out on the long-term effects of “drug holidays” and low adherence. Conducting these types of studies helps scientists, clinicians, and people living with HIV learn about patterns of adherence that may be harmful, and what effect the occasional missed dose might have. We have not yet learned enough to translate these studies into practice, so taking ART consistently is still the best way to keep the virus undetectable.
If you find yourself skipping doses (or wanting to skip them), have an open conversation with your clinician about it. She or he may be able to guide your adherence strategies, discuss simpler regimens, and/or address any side effects or other issues that you may be finding a challenge.

PREPARING FOR YOUR JOURNEY

As you prepare to get your HIV viral load undetectable, there are several things you can do to ensure a successful journey. First, consider your clinician: How’s your “patient-provider relationship”? Do you feel your clinician listens to your questions? Are you comfortable having honest conversations about your ART, possible side effects, and any concerns you have about adhering to your regimen? Good communication with your medical team is essential to getting the care you need as you work toward an undetectable viral load.

Click here for resources to help you build a strong partnership with your doc—or make a fresh start with a new clinician.

Next, you’ll want to set yourself up to create good adherence habits. Although the studies described above suggest that lower levels of ART adherence may not be as harmful as was once thought, the best way to get (and keep!) your HIV undetectable is to aim for consistent adherence to your regimen.

Make an Adherence Plan

Think about your daily routines and consider where taking your medicines will fit. For example, you probably rarely for­get to brush your teeth in the morning, so you might plan to take your medi­cines right before brushing your teeth.
Also think about what motivates you in other areas of your life. Do you reward yourself after cleaning the kitchen or hitting the gym? Can you motivate yourself with the same (healthy!) rewards after a week of solid adherence to your ART?
Finally, it may be helpful to examine your mindset about taking HIV medications. The pills or injections may at first seem like an unwelcome reminder of your virus, but those drugs also show that you are working to beat that virus, manage your health, and take care of yourself.

Ready Your Adherence Devices

Part of your adherence plan may include using medication reminder devices such as cell phone alarms or daily text messages. Personalizing the alarm or text with a motivating message may help.
ART medication packaging can also make a difference. Some people prefer to keep their med­icines in pillboxes marked with the days of the week so they can keep track of the doses they have already taken. Also, some HIV-specialized pharma­cies can package ART in pillboxes or in special daily “bubble” packaging.
Try to keep a supply of ART handy and refill your medicines 5–7 days ahead of time so that you don’t run out and miss doses. If getting to the pharmacy to pick up your medications is problematic, you may want to talk to the pharma­cist about getting medications deliv­ered or mail-ordered. You may also wish to set up automatic refills and reminder calls when your prescrip­tions are ready.

Assemble Your Support Team

Your adherence plan can also in­clude figuring out who your support network is and assembling a team of “medication cheerleaders.” These can be friends, family members, or other people living with HIV—anyone who can provide encouragement as you start new medications and/or deal with challenges to adherence.
You might ask this team to check on you in person, by phone or text, or online. If you are tak­ing a drug that may cause depression or other psychiatric side effects, you might consider asking your support team to watch out for these symptoms and be prepared to help you seek assistance. Sometimes just knowing that people are watching out for you can be comforting and motivating.
Lastly, don’t forget to ask for help from your health care team: your doctors, nurses, pharmacists, social workers, case managers, and others who are rooting for you to succeed in your journey to undetectable.
Jennifer Cocohoba, PharmD, is an associate clinical professor in the School of Pharmacy at the University of California, San Francisco (UCSF). Since 2004, she has worked as the clinical pharmacist for the UCSF Women’s HIV Program, where she provides adherence support and medication information to patients and providers.

Selected Sources

Bangsberg, D. Less than 95% adherence to nonnucleoside reverse-transcriptase inhibitor therapy can lead to viral suppression. Clinical Infectious Diseases 43(7):939–41. October 1, 2006.
Easterbrook, P. and others. The natural history and clinical significance of intermittent viraemia in patients with initial viral suppression to <400 copies/ml. AIDS 16(11):1521–27. July 26, 2002.
Geretti, A. and others. Determinants of virological failure after successful viral load suppression in first-line highly active antiretroviral therapy. Antiviral Therapy 13(7):927–36. 2008.
Palmer, S. Advances in detection and monitoring of plasma viremia in HIV-infected individuals receiving antiretroviral therapy.Current Opinion in HIV and AIDS 8(2):87–92. March 2013.
Parienti, J. and others. Not all missed doses are the same: sustained NNRTI treatment interruptions predict HIV rebound at low-to-moderate adherence levels. PLoS One 3(7):e2783. July 30, 2008.
Rosenblum, M. and others. The risk of virologic failure decreases with duration of HIV suppression, at greater than 50% adherence to antiretroviral therapy. PLoS One 4(9):e7196. September 29, 2009.

BAY AREA HEALTHY LIVING SUPPORT AND COMMUNICATION PLATFORM

At BAYHEAL, we want to mobilize immigrant Africans to take a more positive interest in holistic healthy living, dieting, play and wholeness. But we also want you to get to know us well. You are welcome to reach us on the above number for any questions. Thanks

Some more resources for you!!

I enjoy reading and sharing tips with you.

In this short article I want to talk about four practices that influence the way we all seek health care services:

1. The fear of such diseases like Ebola, yet they are manageable!

2. The care for our oral/buccal cavity

3. Dieting, play and Mental health

4. Reading wider!!

Did you know that Ebola can stay on wall surfaces for over a week? I came across this article and want you to read it: http://www.foxnews.com/health/2015/05/07/ebola-virus-lives-on-hospital-surfaces-for-days/

Help yourself by reading subjects that may not necessarily interest you: http://www.foxnews.com/health/2015/05/07/lowest-number-new-weekly-Ebola-cases-in-west-africa-un-says/

The internet is increasingly becoming accessible and the best way to instruct, seek knowledge, tips, improve on our own practical skills as we continue to lead our lives. A study revealed that there is much written material on almost anything. In our case, I wanted to share with you findings of a study on oral hygiene and braces. Yes, oral hygiene is so important and it should never be overlooked. Also seek information from authentic certifiably credible sources. Please read this article: http://www.foxnews.com/health/2015/05/06/online-info-about-braces-can-be-improved/

If someone advised you to laugh more, drink more water (if you drink little of it or at all), eat more fruits and plan to meet a health care provider regularly, would you think they are blase and a bit boring? Well, well, read this article: http://www.foxnews.com/health/2015/05/07/8-ways-to-boost-your-metabolism/

I cannot over emphasize the need to read wider. It helps you plan better and have more options for leading a quality longer life. I share with you this link: http://www.foxnews.com/health/index.html

ENJOY!