Triumeq (abacavir 600mg, dolutegravir 50mg and lamivudine 300 mg)

TriumeqTriumeq a new single tablet regimen (STR), combining abacavir 600mg, dolutegravir 50mg and lamivudine 300 mg has been approved by the Therapeutic Goods Administration (TGA) in Australia. It is manufactured by ViiV Healthcare and is already available in the US (Aug 2014) and European Union (Sept 2014).

It is the first single-tablet regime that does not contain Truvada (tenofovir disoproxil fumerate/emtricitabine), making it a potential option for those who have impaired kidney function and/or bone toxicity.

Triumeq is considered suitable for ARV treatment-naïve or those without resistance to any of the three ARV agents (abacavir, dolutegravir, lamivudine). A component of Triumeq – dolutegravir, is a second generation intergrase inhibitor and is suitable for those who have resistance to first gen raltegravir and elvitegravir.

Before commencing Triumeq an abacavir hypersensitivity test is conducted, this genetic test screens for the presence of the human leukocyte antigen HLA-B*5701 allele. Presence of the HLA-B85701 allele is strongly associated with a hypersensitivity reaction to abacavir. Without genetic screening the reaction occurs in 5-8% of patients and is most common in those with a Northern European descent. Hypersensitivity to abacavir is a multi-organ syndrome, including symptoms such as rash, fever, fatigue, nausea, diarrhoea, abdominal pain and respiratory issues. Symptoms typically appear in the first 6 weeks of commencing abacavir treatment.

Triumeq can be taken with or without food and there are no restrictions regarding level of viral load or CD4 count.

Triumeq is not yet available on the Pharmaceutical Benefits Scheme (PBS). A decision is expected in Q2 2015.

References

TGA approved Triumeq
FDA Approves New Single-Tablet HIV Regimen, Triumeq
AIDSinfo drug database Abacavir / Dolutegravir / Lamivudine

Australian Treatment Cascade

At the beginning of January I wrote about New Year resolutions for our HIV management. That got me thinking about the treatment cascade. You may not have heard of it, so let me explain.

The HIV care and treatment cascade is a graph which helps us visualise the proportion of:

  • people with HIV in Australia,
  • those diagnosed,
  • linked to care,
  • retained in care,
  • receiving ART (treatment) and
  • having an undetectable viral load (UVL).

The Kirby Institute calculate of the 100% of people in Australia who are HIV-positive about 86% of people know they are living with HIV. 78% & 76% are linked and retained in care. 66% are receiving HIV treatment and 62% have an UVL.

Or as I like to describe:

72% who know they are HIV-positive are accessing HIV treatment and have an UVL’.

poz in oz figure 1

Figure 1: Estimates HIV care and treatment cascade in Australia at the end of 2013

 

So how are we doing compared to other countries?

Well at a conference in Glasgow in 2014 Raymond et al. presented an abstract on ‘Large disparities in HIV treatment cascades between eight European and high-income countries: analysis of break points.’ Or in other words, ‘How do treatment cascades from high income countries compare?’

Australia came in 1st place! We are estimated to have the highest proportion of people living with HIV on treatment with an UVL. I was surprised to find the United States at the bottom of the list, with only 25% having an UVL. This is lower than some sub-Saharan African countries where an estimated 29% of PLHIV have an UVL. Clinicians and public health officials can use these ‘cascades’ to help focus efforts and improve successes, such as increasing HIV testing or better referral pathways.

poz in oz figure 2

Figure 2: Treatment cascade in high-income countries

In Australia it looks like our 2015 HIV management resolutions are already in full swing. Now lets aim for the UNAIDS ambitious targets of 90:90:90. 90% of all people living with HIV knowing their HIV status, 90% of all people diagnosed with HIV receiving HIV treatment and 90% of all people receiving HIV treatment having an UVL.

References:

Estimated HIV care and treatment cascade in Australia (best estimate and uncertainty bounds of plausible limits) “HIV in Australia: Annual Surveillance Report 2014 Supplement”

“Australia performs best in HIV treatment cascade – 62% with undetectable viral load”

New Year Resolutions

new yearLove them or hate them, stick to them or ditch ‘em, New Year resolutions are common talk around this time of year. We promise ourselves acts of self-improvement or doing something nice for others, yet whether they last really depends on our level of motivation.

I consider managing my HIV to be a worthy resolution. Every year I promise myself to remain engaged in clinical care and adhere to my HIV medication. It might seem like a no brainer, but for me after years and years of living with HIV it really does take a back seat to what’s going on in the rest of my life.

Wherever you are on your HIV journey perhaps you can make a New Year resolution about managing your HIV in 2015?

Things you can do to get on and stay on track:

    • Start HIV treatment (if you haven’t already). Studies prove starting treatment regardless of CD4 count has significant benefit to your health, reducing viral load and onward transmission.
    • Adhere to your medication, set an alarm (if like me you get a bit forgetful)!
    • Write down scheduled hospital and GP appointments in your diary, calendar or smartphone. If you’re worried someone might look you could write these in code, i.e. Coffee with Fiona (aka Fiona Stanley Hospital).
    • Work out in advance medication refills. Nothing is worse than stressing you don’t have enough tablets to get you through to Monday!
    • Keep up with regular blood tests, typically every time you collect a new script. This is the only way of knowing the HIV medication is working correctly and you have an undetectable viral load (UVL)
    • Foster a good relationship with a HIV clinician/GP, one where you feel there is a partnership and are confident having a two-way conversation.
      Get help & support for other concerns such as financial vulnerability, mental health, substance use or unstable housing in order to help you fully engage with medical care and adhere to HIV treatment.

Perhaps if you need some help to get started you could schedule an appointment with a support officer at WAAC on 9482 0000. Good luck and let’s kick start our HIV management with a bang in 2015!!!

At the click of a button or get to know me?

Everyone has their own way of disclosing their HIV status and there is no right or wrong. A couple of month back Tyler Curry unashamedly wrote an article regarding how he approaches disclosure.

It drew all sorts of comments. However it did raise an interesting point. In America in gay culture it seems more common for HIV status to be provided on dating app profiles. I haven’t heard of people doing the same thing on RSVP or Tinder.

Heather Boerner’s – Positively Negative: Love, Pregnancy, and Science’s Surprising Victory Over HIV

PositivelyNegativeCoverConceiving a child when one or both partners are HIV-positive used to be the stuff of dreams, but today, modern science allows couples to give birth to HIV-negative babies a reality. A short ebook ‘Positively Negative’ by Heather Boerner sheds light on the developments of reproductive health for those living with HIV and the desire amongst adversity to have a family of one’s own. As Boerner describes it “in both straight couples, the man has HIV, and the women and children remain HIV-negative despite having unprotected sex”.

‘Positively Negative’ guides readers on a 15 year long journey, exploring the reproductive decisions of couples in the U.S. and their different assessments of HIV risk acquisition amongst the landscape of emerging HIV research and treatment development. Historically HIV-positive heterosexuals were discouraged from having children and in the early days pregnant women were encouraged to have abortions. Options for serodiscordant couples (in which one partner is HIV-positive and the other HIV-negative) included adoption, the use of donor sperm or egg, or surrogacy. As early HIV treatment became available more options were offered including sperm washing (using chemicals and a centrifuge to separate the sperm from the seminal fluid) with in vitro fertilization (IVF – the process in which the egg is fertilized outside of the body) or intrauterine insemination (IUI – inserting the prepared semen through the cervix into the uterus), however both were expensive and often difficult to access.

The shining light in this story is how Boerner masterfully intersects two key pieces of modern HIV research into the lives of HIV serodiscordant couples trying to conceive.

  • The Swiss Statement by Dr Pietro Vernazza (2008) from the Swiss Federal Commission for HIV/AIDS stated a HIV-positive heterosexual person is not sexually infectious if:
  • The HIV-positive person had an undetectable viral load (VL < 40 copier/ml) for at least 6 months
  • The HIV-positive person adheres to their daily treatment and was regularly monitored
  • The heterosexual couple were in a monogamous relationship
  • Both partners had no other STI’s

HTPN 052 by Myron Cohen et al. (2011) Prevention of HIV-1 Infection With Early Antiretroviral Therapy

  •  Early initiation of antiretroviral therapy (ART) in HIV-positive individuals reduced the rates of sexual transmission and clinical symptoms, indicating both personal and public health benefits
  • ART reduced the risk of heterosexual transmission by 96%

In the book Boerner follows Susan & Dan Hartmann. They had unprotected sex only when Susan was ovulating and Dan adhered to HIV medication and consistently had an undetectable viral load. Susan meticulously kept calendars and used ovulation-testing kits. They reassessed this process 6 monthly and Susan had the right to refuse unprotected sex at all times. They also openly discussed what it would mean if Susan contracted HIV. It took just two months for the pregnancy test to come back positive. Susan remained HIV-negative. In 2009 their HIV-negative daughter Ryan Nicole was born.

Boerner also followed Ted Baker and Poppy Morgan. They also had unprotected sex with Ted adhering to his HIV medication and consistently having an undetectable viral load. In addition, Poppy took Truvada as a Pre-Exposure Prophylaxis (PrEP) medicine, approved to prevent HIV-negative people from contracting HIV. Poppy continues to keep a blog of their experiences HIV-negative spouses In 2013 their HIV-negative daughter nicknamed Pom-Pom was born.

Some people uneducated about modern HIV treatment may think people living with HIV trying to conceive should not be allowed to have condomless sex. However the evidence is clear and with consistence clinical care there is minimal risk. Both couples in this story were responsible risk takers and their foray into ‘wild unprotected sex’ was instead highly structured.

Boerner also touches on stigma and recognises a difference around fear of the HIV virus between generations. Caroline Watson, born in the late 80’s says:

As long as you’re taking care of it, you’re not going to get sick, you’re not going to get AIDS and you’re not going to die of it.” What you will die of, she said, is shame: People who are ashamed of having the virus don’t go to the doctor and don’t take their medicine. People who are ashamed don’t tell their partners, and put them at greater risk of infection.

While Boerner herself admits to “having grown up in the 80’s, and remembering how terrifying the early virus was, my entire sexual life developed around fear of the virus. As a girl, I wasn’t just afraid of getting pregnant. I was afraid that any little slip up and I could be that girl in a wheelchair in my 20s, dying.” “The more I listened to Watson’s staccato, matter-of-fact cadence as she talked about her approach to the virus, the more I realised that the problem is with me and the rest of us whose image of the virus froze in the 1980s.”

This ebook is a fantastic read not only for serodiscordant couples, but anyone living with HIV, the clinicians, GPs and nurses who treat them and the wider community who are interested in HIV. It sheds light onto the emotional and medical struggles to conceive an HIV-negative child in a time when HIV is classified as a chronic illness and HIV-positive people have a normal life expectancy. Perhaps the only let down is Boerner not following a HIV-positive woman in a serodiscordant relationship conceiving and giving birth to an HIV-negative baby. However, in Boerner’s words ‘it is a story of how super-powerful HIV medications have changed the social landscape as well as the medical one. It is a story of risk and possibility, of the promise of family and the fear of a resurgence of the virus’.

If you are HIV+ and interested in starting a family discuss your options with your HIV clinician 

You can find ‘Positively Negative: Love, Pregnancy, and Science’s Surprising Victory Over HIV’ [Kindle Edition] by Heather Boerner here

Check out these links for further information:

A replacement for that morning coffee?

POZINOZ Berry SmoothieOk, so most of us need a coffee to get us going in the morning, but how about this healthy alternative?

Ingredients:
1 cup of frozen mixed berries
1 cup of coconut water

Method:
Put them in the blender (on a smoothie cycle if you have one). 30 seconds – 1 minute
This will make the equivalent of a medium cup of coffee. You can even pour it into your travel mug and drink it on the way to work!

Mixed berries have high levels of antioxidants and are great for fighting free radicals, which cause oxidative stress. There is evidence that oxidative stress can contribute to several aspects of HIV disease, including viral replication, inflammatory response and decreased immune cell proliferation1. Coconut water is high in potassium which helps maintain fluid and electrolyte balance, reducing fatigue and hypertension (high blood pressure).

1Aquaro, S., Scopelliti, F., Pollicita, M. & Perno, C. F. Oxidative stress and HIV infection: target pathways for novel therapies? Future HIV Therapy, 2008; Vol. 2, No. 4, Pages 327-338