April 24, 2017
The annual Conference on Retroviruses and Opportunistic Infections (CROI) is an annual gathering where advocates and researchers learn where the science on HIV is taking us. The findings can be both grand and granular. They answer questions, raise new ones or both. And not all of those questions are strictly about science. Two of AVAC’s partners have been reflecting on what they took away from the conference, insights that inform our thinking long after the sessions end and results are published.
Rob Newells is an Associate Minister at the Imani Community Church in Oakland, California, and serves as Executive Director for AIDS Project of the East Bay—a community-based organization serving the most vulnerable and marginalized communities in Alameda County since 1983. He was a 2011 Fellow of the Black AIDS Institute’s African American HIV University Community Mobilization College and has been a biomedical HIV prevention research advocate with AVAC’s US PxROAR group since 2012.
There are conferences that I attend where I can be “Rob Newells, Executive Director for AIDS Project of the East Bay (APEB).” The Conference on Retroviruses and Opportunistic Infections, more commonly known as CROI, is not one of those conferences. At CROI, the ED hat comes off, and I’m purely a community advocate again. This year, that was even more true than in previous years. As I looked around the room of Community Educator Scholars (a program that supports advocates attending CROI) as we gathered for our first early morning breakfast of the week, I immediately noticed that I was the only African American man at the table. There were two African American women (one Scholar and one member of the Community Liaison Subcommittee) and several Africans (shout out to my brothers Ntando, Simon and Supercharger), but no other Black men from the United States. It wasn’t the first time that I’ve been the only one, and I know it won’t be the last, but—if I’m being honest—I was both disappointed and stressed by it. I felt a lot of pressure to be the eyes and ears for my community in a way that I hadn’t felt in previous years.
From a community perspective, CROI is the most boring meeting I attend. It’s 4,000 science and research geeks talking to each other about what they’ve been doing locked away in their labs for the last few years. Most of the news that gets reported after CROI is for science and research geeks, and those reports usually miss the things that I find interesting or that I think my community would find interesting, useful, and relevant. So, in an attempt to rectify that shortcoming, I attended all of the plenary sessions and a bunch of the oral abstract sessions and even took my time to talk to presenters during the poster sessions. I took lots of notes and pictures of slides, and when I returned home (after another conference the following week) I talked it all through with my staff. It took a while longer for me to organize my thoughts into a coherent presentation that I could use for the community report-back I coordinated at the Alameda County Public Health Department on National Women and Girls’ HIV/AIDS Awareness Day. This is some of what I shared.
CDC’s oral presentation on HIV Incidence, Prevalence and Undiagnosed Infection in Men Who Have Sex with Men gave us good news and bad news. The good news is that the percentage of undiagnosed HIV infections decreased for all racial/ethnic groups between 2008 and 2014. (That tells me we’ve been doing a better job of testing.) The bad news is that there was an increase in HIV incidence among Latino MSM and MSM between the ages of 25 and 34. (Annual infections among Black MSM dropped from 10,100 in 2008 to 10,000 in 2014. I don’t see that as anything to write home about, but a decrease is a decrease, right?)
Anal Cancer
I had my third or fourth high resolution anoscopy (HRA) just before CROI, so I was particularly interested in a few of the abstracts related to anal cancer. (There were seven posters and four oral abstract presentations on anal cancer this year, so I wasn’t the only one interested.) While anal cancer is fairly rare overall, men living with HIV who have sex with men are 60-190 times more likely to get anal cancer than the general population. We know that certain types of HPV are responsible for most anal cancers, and most MSM living with HIV have HPV of one type or another. What we didn’t know was what we should be doing about it. What I took away from CROI 2017 was that anal cancer screening should start at 30 to 35 years old for MSM living with HIV. Insured folks like me should get an annual HRA. Unfortunately, HRA is not the most cost-effective prevention tool, and resources to perform the test are limited worldwide. Additionally, patients who rely on the Ryan White AIDS Program or Medicare for coverage have to settle for a digital rectal exam (exams where the doctor inserts a gloved, lubricated finger into the anus to feel for unusual lumps or growths) to detect anal cancer because an HRA isn’t covered. As fun as a digital rectal exam may sound, it’s not that effective. HRA detects the most cancers. (I know from personal experience. I asked my primary care physician to refer me for an anal pap smear and HRA a few years ago. He didn’t find anything suspicious with the digital rectal exam, but he gave me the referral anyway. The HRA found a stage 4 pre-cancerous lesion which was removed during the procedure. Thank you, Kaiser Permanente.)
Antibodies
Bridge HIV in San Francisco is one of the sites for the AMP (antibody mediated prevention) Study, and I know people in my community who are enrolled so I paid attention. Antibodies are a big deal in HIV research. My takeaway from CROI was that the current study won’t produce a home run that will work for everyone. Researchers hope to have an understanding about whether or not antibodies can work for prevention, but as public health intervention it is cumbersome, involving monthly clinic visits and transfusions. And no matter the results from AMP, vaccines based on neutralizing antibodies are still a long way off.
Cure Research
There were two things I found interesting in the cure research presented this year. The first was that people on effective antiretroviral therapy are not producing new HIV-infected cells. Cells proliferate before they die off. That means that earlier detection and treatment results in fewer proliferating cells with less diversity and smaller reservoirs. That might make HIV easier to target and cure. The other thing that caught my attention was that estrogen blocks RNA replication. That discovery leads to at least two pathways to cure: Can we block estrogen to bring latent cells out of hiding (the “flush and kill” strategy), or can we increase estrogen to keep RNA blocked (the anti-proliferation model)?
Drug Use and MSM
Over the past few years, I have heard from friends in Oakland and Atlanta that there was an increasing problem with crystal meth use among Black MSM. I’ve had conversations with many of my colleagues about the increasing mention of PnP (Party and Play) on dating/hook-up app profiles. For years, the common assumption has been that meth is for white boys, but apparently more and more black men are going that route. There were a couple of posters about drug use and MSM that I totally expected to confirm that for me. The first, from CDC, looked at drug use by MSM in 20 cities across the United States. Surprisingly, they didn’t see an increase in meth use. They saw an increase in prescription opioid use among Black MSM between 2008 and 2014. But just two steps away, the very next poster from George Washington University noted a drastic increase in crystal meth use among Black MSM in Washington, DC, over the same time period. I totally expect to see more research in this area.
Pre-Exposure Prophylaxis (PrEP)
What I heard coming from Seattle about pharmacist-managed PrEP was intriguing. Being able to avoid the cost of a clinic visit could greatly increase access and uptake. I contacted my agency’s pharmacy partner when I got home to find out if they had the ability to order labs and prescribe Truvada for PrEP without patients having a clinic visit. (They can, and we will.)
And there was good news for women. Apparently, there was some confusion after all of the talk about good and bad bacteria in the vaginal microbiome at AIDS 2016. That was in relation to vaginal microbicides. Oral PrEP doesn’t go through the vagina, so the vaginal microbiome has no effect on blood and tissue levels of the drug. Oral PrEP works for women. Period.
There were a few other abstracts dealing with community cohort care for adolescents, HIV testing incentives, and text messaging interventions for PrEP users that were interesting enough for me to mention to the folks at home, but if I’m being honest, I was looking for something else.
CROI 2017 was the first conference in an entire year where I didn’t hear anything from the HPTN-073 team. Instead we heard from a team at Emory University, but what I heard only annoyed me. I don’t need another study that tells me how Black MSM don’t use PrEP. The study led by black men for black men (HPTN-073) showed us what works. Emory presented yet another study that showed us what doesn’t work. They studied Black MSM aged 16 to 29 in Atlanta. Participants were offered risk reduction counseling, condoms and lube, and non-incentivized oral PrEP. After viewing a brief education video from WhatIsPrEP.org, the men who expressed interest were scheduled to see a study clinician to initiate PrEP.
The study results indicated that 56 percent of the men expressed interest but 39 percent of those never showed up for the initiation visit with the clinician. Of the ones that did come back, only 35 percent initiated PrEP. The study team’s conclusion was that, “even after amelioration of structural barriers that can limit PrEP use,” PrEP uptake was suboptimal. What structural barriers, you ask? Only lack of health insurance was addressed. (As if that’s the most pressing structural barrier Black MSM face in the United States.) When I asked about what else was done to engage these men based on what we know from HPTN-073, I was told that there is really “no hard, a priori evidence that more aggressive interventions are needed” for Black MSM.
I sat down so that I wouldn’t come off as the angry Black man, but when 79 percent of the participants in HPTN-073 accepted PrEP after a series of counseling sessions that combined service referral, linkage and follow-up strategies to address unmet psychosocial needs (part of what that team calls C4, or client-centered care coordination), I would argue that the need for more aggressive interventions is obvious. A study led by black men told us how to work with black men. Apparently, someone needs to fund more “For Us, By Us” studies so that we have a body of evidence showing what works because I’m tired of hearing what doesn’t work.
There were no exciting results from large efficacy trials at this year’s CROI like there have been for the last several years. It was back to basic science. That means the conference was even more boring than it normally is. But when I returned to Oakland and put my E.D. hat back on, I realized that I had the power to implement some of what I learned without waiting for studies to be published or government agencies to catch up to the science which could take years. I had the power.
In addition to client-centered care coordination and pharmacist-managed PrEP, we are in the process of adding an optional SMS intervention to the PrEP program at APEB, and we’ve started working with La Clinica de la Raza—a local community-based organization that prioritizes Latino populations—to support efforts to address the increasing HIV infection among Latino MSM. That’s why I go to CROI. That’s why I’m grateful to the scholarship committee for supporting my attendance and to AVAC for always providing what I need in order to stay on top of new developments in biomedical HIV prevention research. That’s why I wish I wasn’t the only African American man at those daily 7am breakfast meetings.
…cue Solange’s “F.U.B.U.”