Laura Waters

This session incorporated a characteristically impassioned & accessible plenary from Tony Fauci on treatment/prevention gaps in addressing the HIV pandemic. A presentation first for the Volkow siblings: Nora Volkow covered the consequences of the opioid crisis in terms of HIV and Patricia Volkow summarised the latest data on Kaposi's Sarcoma.

Replacing daily ART is the ultimate treatment goal. Treatment as prevention, though critical, won’t dramatically decrease HIV incidence alone – PrEP essential. Long-acting PrEP options include ART (phase 3 IM cabotegravir pending) & BNAbs but Fauci considers a vaccine still crucial with multiple ongoing trials exploring a range of approaches. US opioid epidemic increased overdose deaths & IDU, with HIV outbreaks in the most affected counties. Medications for opiod use disorders (MOUD) associated with reduced HIV transmission (>50%), improved ART adherence (two-fold), increased viral suppression & reduced mortality. Primary care MOUD as good as specialist & prison programmes beneficial. KS can have multi-system & stigmatising manifestations. KSHV viral load correlates with disease severity & should be measured. ART+chemotherapy recommended for disseminated KS where mortality remains significant. Valganciclovir four weeks prior to cART initiation for disseminated KS which demonstrated, in patients with KSHV >1000 copies/ml, decreased IRIS severity and attributable mortality.

As exciting as BNAbs & vaccine research sounds, as we’ve all learned over the (many) years, very cautious optimism is probably as far as our feelings should stretch right now. “We have a number of eloquent tools” said Fauci, “many are accessible right NOW” says me so equitable access to antiretrovirals, for treatment & prevention, must be our priority. Lack of needle exchange & MOUD both drive HIV outbreaks in PWID but the MOUD cascade is pitiful. KSHV should be standard of care in KS management and 4 weeks of valganciclovir prior to ART imitation may provide IRIS-related benefits.