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Progress tempered by reality of HIV control at 17th CROI

Guest blog by Steven Welch, Consultant in Paediatric HIV and Infectious Diseases, Heartlands Hospital, Birmingham, United Kingdom.

Today is the fourth and last day of the 17th CROI (Conference on Retrovirology and Opportunistic Infections) in San Francisco. There is immense enthusiasm here for the range of tools we now have to prevent and treat HIV infection. But this optimism remains tempered by the reality of our shortcomings in delivering these in practice, in both low- and high- income countries.

We have heard presentations that detail how HIV enters new hosts. This knowledge is vital to developing a more effective HIV vaccine, following reports of the first partially effective vaccine last year. A vaccine alone will not stop the global epidemic. Control of HIV will come from combining a number of prevention strategies that have been discussed here: testing and drug treatment (ART) to reduce infectivity; adult male circumcision; scaling up ART for women to prevent transmission in childbirth and breastfeeding; and better targeted education messages. Data show that most people in Africa with HIV do not know their infection status, and high numbers of uninfected people in sero-discordant couples do not know that they are at risk.

New advances presented at this CROI include preliminary data on Gilead’s new “quad pill” which combines 2 new and 2 established drugs in a single once-daily pill, and a handful of new drugs in development in existing classes. But new data here have not shown much benefit from intensifying successful drug combinations by adding new classes. We have been reminded that we still have much to learn about long term drug toxicities by data associating duration of tenofovir use with decline in renal function.

Yet advances mean nothing if not implemented, and a recurring theme this week has been the gap between what we know we could achieve, and what is actually being done. We have heard warnings of the impact of the global economic crisis on longterm funding for HIV control, and presentations have reminded us of how patchy access to HIV services remains in both rich and poor countries.

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