The 25th Bangkok International Symposium on HIV Medicine

Abstract

Proceedings of: 25th Bangkok International Symposium on HIV Medicine, 18–20 January 2023, held virtually and on site at Samyan Mitrtown Hall, Bangkok, Thailand.

The Bangkok International Symposium on HIV Medicine has commenced on the third Wednesday of January since 1998. The Symposium aims to provide professional healthcare workers in Thailand and the region an opportunity to receive the most up-to-date information on HIV and its related conditions if they are unable to attend other HIV conferences abroad. This year’s hybrid symposium was held from 18 January to 20 January 2023. A total of six plenary sessions were held in the mornings, and four afternoon workshops held on Wednesday and Thursday. Expert speakers from Thailand, China, Malaysia, Singapore, India, Hong Kong, the Philippines, Australia, the UK, The Netherlands and the USA participated in the symposium.

Keywords::

• aging
• comorbidities
• COVID-19
• hepatic diseases
• HIV
• prevention
• treatment
• tuberculosis

Day 1, session 1: COVID-19

Sharon Lewin (The Doherty Institute and University of Melbourne, Melbourne, Australia) reviewed “Antiviral strategies for COVID-19: the importance of therapeutics in current and future pandemics”. The antivirals remdesivir, nirmatrelvir/ritonavir and molnupiravir are licensed for treatment of mild-to-moderate disease, reducing the risk of hospitalization or death by up to 87, 89 and 31%, respectively. Molnupiravir offers no benefits in younger vaccinated adults [1]. The monoclonal antibodies tixagevimab plus cilgavimab (Evusheld) prevent COVID-19 acquisition in immunocompromised patients [2]. All Omicron variants have reduced sensitivity to currently available antibodies [3]. The reprogrammed Cas13b-CRISPR system has the potential in antiviral drug development to suppress SARS-CoV-2 mutants [4].

Gail Matthews (The Kirby Institute, University of New South Wales, Sydney, Australia) gave the Cooper Memorial plenary on “Risk factors, pathogenesis and management of long COVID”. Long COVID is a post-COVID-19 condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection usually 3 months from symptom onset, often lasting for 2 months or more and cannot be explained by alternative diagnoses [5]. Risk factors for long COVID include being of the female sex, an ethnic minority, having other comorbidities, smoking and a lower socioeconomic status [6]. Potential causes identified in vitro include viral antigen persistence, inflammation, herpes virus reactivation, dysbiosis, microvascular dysfunction and autoreactive immune responses [7]. Vaccination reduces long COVID risk by 15–42% [8].

Adeeba Kamarulzaman (University of Malaya, Kuala Lumpur, Malaysia) gave the Lange Memorial Plenary on “Inequities in health: how has COVID-19 prepared us for future pandemics?”. Health equity is defined as, “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically” [9]. Deconstructing health inequity from global through to individual patient levels allows identification of areas for promoting equity, including: solidarity (the mRNA Hub); improved access to interventions (vaccination, genomics technology for diagnostics, testing and treatment); and innovation (surveillance, contact tracing, smartphone apps/telemedicine).

Session 2: Prevention

Joel Palefsky (University of California, CA, USA) presented the results of the ANCHOR study, which found that in people living with HIV (PLWH), ablative treatment of anal high-grade squamous intraepithelial lesions (HSIL) reduced progression to anal cancer by 57%, compared with active monitoring without treatment [10]. CDC guidelines will soon recommend screening and treatment of anal HSIL as the standard-of-care for PLWH. Asia has poor capacity to screen and treat anal HSIL. Scaling-up high resolution anoscopy training [11], to teach local clinicians about lesion diagnosis and treatment is a priority.

Suwat Chariyalertsak (Faculty of Public Health and Research Institute for Health Science (RIHES), Chiang Mai University, Thailand) discussed “New HIV prevention modalities in low-middle income countries: the way forward to ending AIDS in 2030”. Despite the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV transmission, PrEP is underutilized in some. Long acting intramuscular cabotegravir (LA-CAB) given every 2 months showed better efficacy than daily oral tenofovir disoproxil and emtricitabine (TDF/FTC) or tenofovir alafenamide and emitricitabine (TAF/FTC) in preventing HIV transmission [12,13]. LA-CAB for PrEP is recommended for high-risk populations, but not licensed in all Asian countries.

Rayner Kay Jin Tan (University of North Carolina Project-China, NC, USA) discussed “Challenges in HIV prevention in adolescents and young adults (AYA) in the Asia Pacific (APAC)”. New HIV infections among AYA, especially men who have sex with men, in the APAC is alarmingly high. Lack of family support, fear of disclosure and a high prevalence of mental health issues are challenges, so improved integration of HIV and mental healthcare is a priority. Youth led peer support networks have a central role in responses [14].

Day 2, session 1: TB

Frank Cobelens (Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands) discussed “Is ending TB is possible?”. Global TB control strategies for 2015–2035 focus on prevention, contact investigation, community engagement, universal health coverage and research and innovation. Reducing TB incidence and ending TB requires: early diagnosis (rapid, simple, inexpensive tests) and treatment; prevention (accurate tests to identify incipient TB, treatment to prevent active disease, drug resistance testing); effective vaccine development and improving living conditions by reducing poverty (the key epidemic driver).

Amita Gupta (Division of Infectious Diseases, John Hopkins University, MD, USA) discussed TB prevention and treatment among pregnant women. TB burden in pregnant PLWH in high burden settings is high, ranges from 0.6 to 11%, but is under-reported. Pregnant PLWH are at an increased risk for TB, and TB impacts maternal–infant outcomes. Latent TB diagnostic tests have reduced sensitivity during pregnancy. Pregnant women with multidrug resistant TB (MDR-TB) have treatment success rates comparable with other populations [15], but data on TB preventive therapy in pregnant women is limited.

Charoen Chuchottaworn (Chest Disease Institute, Nonthaburi, Thailand) talked about updated diagnosis and treatment of MDR-TB. The WHO recommends the use of Xpert MTB/RIF and Xpert Ultra as initial tests in adults and children with signs and symptoms of pulmonary TB. The new Xpert MTB/XDR identifies resistance to five drugs, including isoniazid. Rapid molecular testing will soon be the gold standard for MDR-TB and pre-extremely drug resistant (XDR) TB diagnosis. Updated WHO guidelines for MDR/RR-TB and pre-XDR-TB recommend 6 months of bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM), reduced from ≥9 months.

Session 2: hepatic diseases & aging

Sombat Treeprasertsuk (Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand) talked about management of nonalcoholic steatohepatitis in PLWH. Nonalcoholic fatty liver disease (NAFLD) has been changed to metabolic dysfunction associated fatty liver disease (MAFLD). Differences exist between NAFLD and MAFLD diagnosis and mortality. MAFLD can cause extrahepatic complications, such as cardiovascular disease (CVD) and chronic kidney disease. Using fibrosis scores followed by liver stiffness measurement can accurately detect advanced fibrosis. NAFLD management requires a multifaceted approach, including weight control.

Grace Chung-Yen Lui (Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong) discussed “Phenotypic aging, frailty and comorbidities in PLWH”. Factors contributing to aging include AIDS defining illnesses, inflammation, HIV reservoirs, antiretroviral therapy and polypharmacy. ‘PhenoAge’ predicts frailty better than chronological age in PLWH [16]. PLWH have an earlier onset of age related comorbidities and a reduced quality of life. Lack of social support, stigma and negative attitudes toward elderly PLWH reduces resilience. Comprehensive multidisciplinary aging assessments are recommended.

Day 3, session 1: prevention & management of comorbidities

Sanjay Pujari (Institute of Infectious Diseases, Pune, India) discussed prevention and management of CVD in PLWH. Acute myocardial infarction (AMI), ischemic stroke, heart failure, pulmonary hypertension and arterial thrombosis are more common in PLWH [17]. Lifestyle risk factors, combination antiretroviral therapy and persistent immune activation contribute to CVD and AMI. Regular assessments and modification of CV risk should be incorporated into routine HIV care. Currently available CV risk-prediction tools need refinement.

David Burger (Radboud University Medical Center, Nijmegen, The Netherlands) provided a historical overview of pediatric antiretroviral pharmacology, including the new, important role of dolutegravir (DTG). DTG is effective as a component of first and second-line pediatric regimens [18], and twice-daily dosing in children with TB is adequate and safe. New pediatric DTG formulations (dispersible tablets) improve adherence but are not yet available in Asia-Pacific countries. Generic DTG dispersible tablets, DTG-containing pediatric fixed-dose combinations and long-acting injectables are needed.

Anton Pozniak (Chelsea and Westminster Hospital and London School of Hygiene and Tropical Medicine [LSHTM], London, UK) discussed the treatment and prevention of monkey pox transmission. Approved treatments are tecovirimat, cidofovir, brincidofovir and vaccinia immunoglobulin. Treatment should be administered to people with severe disease and those at high risk of severe disease, including immunocompromised hosts and children. Monkeypox can be prevented by promptly treating those infected and providing post exposure management to minimize the onset of illness.

Session 2: treatment update

Anthony Kelleher (The Kirby Institute, University of New South Wales, Sydney, Australia) provided an update on HIV eradication and control. To achieve a cure, HIV latent reservoirs must be eradicated. Only four adults who underwent allogenic bone marrow transplants for hematological malignancy are known to be cured of HIV. This strategy is not viable in people without malignancy, and identifying donors that are an HLA match and with CCR5 deletion is difficult. He discussed gene therapies used to induce changes in the histone tails and nucleosome architecture to permanently ‘lock’ cells into latency.

Kulkanya Chokephaibulkit (Faculty of Medicine, Mahidol University, Bangkok, Thailand) talked about ‘Treatment issues in adolescents and young adults (AYA)’. About 40% of new infections occur in people aged <25 years. DTG is a component of first- and second-line regimens, with efficacy >90% in AYA [18]. Combination of bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) is an ideal choice for AYA due to potency, once-daily dosing and small tablet size. LA-CAB with rilpivirine (RPV) was approved for adolescent use in 2022. Long-term complications, mental health, disclosure and transition to adult care were discussed.

Kiat Ruxrungtham (Vaccine Research Center, Chulalongkorn University, Bangkok, Thailand) talked about the evolution of adult HIV care. DTG and BIC have high genetic barriers and superior efficacy to efavirenz, so DTG is recommended as the first-line therapy in all guidelines. DTG/TAF/FTC is cheap, potent, with low drug resistance, few toxicities and drug–drug interactions and is kidney and bone friendly. Dual regimens (DTG/lamivudine [3TC], DTG/RPV and CAB/RPV-LA injectable) can be used in people without HBV co-infections, chronic kidney disease with dialysis or obesity. Fixed-dose combinations, improved tolerability and ART adherence, fewer drug–drug interactions and food restrictions, better long-term safety, lower cost and availability of LA injectables all help to increase the survival of PLWH and improve their quality of life.

The next symposium, 26th Bangkok International Symposium on HIV Medicine, will be held on 17–19 January 2024.

Acknowledgments

The authors thank all of the speakers for providing the latest information on HIV to the symposium, the chairpersons for coordinating with the speakers for the workshop, and the scientific committee for their advice in developing the program. Also, we would like to thank the Bangkok Symposium Team, especially K Nanthapisal, C Ruengpanyathip and E Phuengchangam.

Financial & competing interests disclosure

The 25th Bangkok International Symposium on HIV Medicine was supported by ViiV GSK, Gilead and DCH Auriga, Sysmex Asia Pacific Pte Ltd, Oxford Immunotec Limited, amfAR/TREAT Asia, Atlanta, Camber Pharmaceuticals, Cepheid, Abbott, The Government Pharmaceutical Organization (GPO), UNSW Kirby Institute and Thailand Convention and Exhibition Bureau (TCEB). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Additional information

Funding

The 25th Bangkok International Symposium on HIV Medicine was supported by ViiV GSK, Gilead and DCH Auriga, Sysmex Asia Pacific Pte Ltd, Oxford Immunotec Limited, amfAR/TREAT Asia, Atlanta, Camber Pharmaceuticals, Cepheid, Abbott, The Government Pharmaceutical Organization (GPO), UNSW Kirby Institute and Thailand Convention and Exhibition Bureau (TCEB). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.