Abstract: In the era of antiretroviral therapy, HIV infection has become a chronic illness with associated multimorbidity, and practitioners are faced with an emerging population of HIV-infected patients with evolving needs for advance care planning (ACP), defined as communication between individuals and their proxies to plan for future health care decisions. This article provides a review of original research studies on ACP in HIV-infected adults in the era of antiretroviral therapy (1996-present) from PubMed, EMBASE, and PsycINFO. Eleven studies conducted between 1996 and 2015 met the selection criteria, with study sizes ranging from 9 to 2864 participants. Most studies consisted of white men in outpatient settings and had poorly defined definitions of ACP. Prevalence of ACP was variable (36%-54% had end-of-life communication, 8%-47% had advance directives). Lack of ACP was most commonly associated with low income, followed by lower severity of illness, low education level, black or Hispanic race, female sex, younger age, injection drug use, and social isolation. Practitioners reported limited time or energy and inadequate preparation or training as barriers to ACP. Existing literature on ACP in the era of antiretroviral therapy is limited, but shows that ACP prevalence in HIV-infected individuals is variable depending on socioeconomic factors, severity of illness, and practitioner resources and training. More research is needed to increase ACP among HIV-infected individuals.

Abstract: The HIV care continuum (or treatment cascade) classifies individuals with HIV infection who are diagnosed, linked to care, retained in care, on antiretroviral therapy, and virally suppressed, to assess the effectiveness of health care and treatment from a population-level health perspective. Initially, it was estimated that only approximately 50% of individuals diagnosed with HIV infection are retained in care, and a lower percentage is virally suppressed. In an HIV clinic, retention in care should be addressed from a system perspective but focus on persons on an individual basis, and success in retention of a high proportion of individuals in care is likely to depend on collaboration with surrounding communities, local health departments, and other agencies. Two initiatives to improve engagement and retention in care undertaken at the University of Alabama at Birmingham 1917 Clinic are discussed. This article summarizes a presentation by Michael J. Mugavero, MD, MHSc, at the Ryan White HIV/AIDS Program Clinical Care Conference held in New Orleans, Louisiana, in December 2015.

Abstract: A recent outbreak of HIV infection centered in the rural town of Austin in Scott County, Indiana, was associated with widespread injection drug use and a socio-economically depressed population. Control of the outbreak required coordinated efforts by state, federal, local, and academic institutions to implement and maintain on-site programs and services that included contact tracing, HIV and hepatitis C virus testing, insurance enrollment, syringe exchange, rehabilitation services, care coordination, preexposure prophylaxis, and HIV treatment. This article summarizes a presentation by Diane M. Janowicz, MD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Los Angeles, California, in April 2016.

Abstract: The 2016 Conference on Retroviruses and Opportunistic Infections (CROI) highlighted hot spots in HIV infection. Men who have sex with men (MSM), transgender populations, people who inject drugs, fisherfolk, migrants, adolescents, and older adults are heavily impacted in a number of regions. Stigma contributes to risk behaviors and HIV acquisition across populations. HIV testing is a crucial first step in the HIV care continuum, and several large community-based surveys are underway in Africa to increase HIV testing, linkage to care, and uptake of antiretroviral treatment. Advances in preexposure prophylaxis (PrEP) featured prominently at CROI 2016. Two large efficacy trials of a vaginal ring containing the investigational drug dapivirine demonstrated efficacy and safety in preventing HIV infections in women in Africa. Data on the safety of long-acting injectable PrEP and several investigational PrEP drugs and formulations were also presented. Knowledge and use of PrEP among MSM in the United States appears to be increasing, and high uptake was seen among black MSM when provided as part of a culturally tailored support program. The use of broadly neutralizing antibodies for HIV prevention is a novel and promising approach to be evaluated in efficacy trials.

Abstract: HIV disproportionately impacts populations that have traditionally suffered from health disparities; thus, it is unsurprising that health disparities are a major driver of the ongoing HIV epidemic in the United States. High rates of HIV prevalence and incidence are now seen in the Southern United States and among black men who have sex with men, transgender women, and individuals in low-income settings. In addition, substance use continues to be a major driver of the HIV epidemic and impacts care outcomes. Efforts at reducing HIV transmission must include focus on engagement and retention in care among individuals at risk of being lost to care. This requires particular emphasis on understanding and addressing patient needs and removing structural barriers to engagement in care. This article summarizes a presentation by Carlos del Rio, MD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in New York, New York, in March 2016.

Abstract: Antiretroviral therapy is recommended for all patients with HIV infection. The benefit of immediate antiretroviral therapy was confirmed by results from the START (Strategic Timing of Antiretroviral Treatment) trial, which showed a 57% reduction in risk for the composite end point of AIDS-related events, serious non-AIDS-related events, or death from any cause with immediate treatment in antiretroviral therapy-naive participants with CD4+ cell counts above 500/µL. Other changes in HIV care include the widespread adoption of integrase strand transfer inhibitor-based regimens. Considerations regarding when to initiate antiretroviral therapy, which initial regimens to use, and appropriate monitoring of individuals taking antiretroviral therapy are discussed. This article summarizes an IAS-USA continuing education webinar presented by Steven C. Johnson, MD, in July 2015.

Abstract: Current guidelines for managing cholesterol to reduce cardiovascular disease (CVD) risk focus on providing the appropriate intensity of statin therapy to reduce low-density lipoprotein cholesterol (LDL-C) level. There is very little evidence supporting the use of treatments aimed at raising high-density lipoprotein cholesterol level or reducing triglyceride levels. HIV-infected persons have excess risk of CVD compared with the general population. Statins are less effective at reducing LDL-C levels in HIV-infected persons who are also at greater risk for adverse effects from statin treatment. When selecting a statin to achieve desired lowering of LDL-C level, the potential for drug interactions with antiretroviral therapy must be considered. Information from ongoing research is expected to help identify optimal strategies for use of statin treatment in this population. This article summarizes a presentation by James H. Stein, MD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Chicago, Illinois, in May 201.

Abstract: Diagnosis of acute HIV infection is important for accurate estimation of HIV incidence, identifying persons who are unaware of their HIV infection, and offering immediate treatment and risk-reduction strategies. The higher viral loads associated with acute HIV infection are associated with an increased risk of transmission. Current treatment recommendations are the same for acute and established infections. Studies of acute HIV infection indicate that initiation of antiretroviral therapy during this period may allow greater recovery of CD4+ T-cell count and function and may result in a smaller latent viral reservoir and a skewing of infection away from central memory CD4+ T cells toward shorter-lived transitional memory CD4+ T cells. This article summarizes a presentation by Susan J. Little, MD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Los Angeles, California, in April 2015.

Abstract: The potential for drug-drug interactions is an important consideration in the treatment of HIV/hepatitis C virus (HCV) coinfection. Regimens for HCV genotype 1 infection are discussed in the context of an individual on stable antiretroviral therapy, to determine which HCV treatments may be initiated without requiring a change in antiretroviral regimen or an increase in monitoring for potential drug-drug interactions. The effects of potential interactions between HCV drugs and other therapeutic classes of drugs are also discussed. This article summarizes a presentation by Jennifer J. Kiser, PharmD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Los Angeles, California, in April 2016.

Abstract: Global climate change exacerbated by human energy use threatens to have a profound impact on human health, including from infectious diseases. Particularly vulnerable populations include the immunocompromised, including persons with HIV infection. Global warming can be expected to increase the geographic range of pathogens such as Vibrio cholerae as well as vectors that transmit disease, including ticks and mosquitoes. Higher temperatures also contribute to increased pathogen and vector efficiency in spreading disease. Natural disasters due to climate change result in population displacement, increased population density, and living conditions conducive to the spread of infectious diseases. Political mobilization is crucial to implementing and enforcing policies for prudent energy use, reversing the drivers of global warming, and ensuring that we are prepared for the adverse health consequences of climate change. This article summarizes a presentation by Robert T. Schooley, MD, at the IAS-USA continuing education program held in Berkeley in May 2017.

Abstract: Access to newer therapies for the treatment of hepatitis C virus (HCV) infection is limited by the costs of these treatments. Newer HCV regimens have been shown to be cost-effective in early stages and late stages of the disease, but payers in the United States may refuse to reimburse for treatment of early disease because of budget constraints. Approaches that can maximize patients' access to appropriate therapy include having dedicated staff to handle prior authorizations and appeals, keeping records of successful approaches to prior authorizations and appeals and sharing these approaches with colleagues, and communicating with patients so that they will not be lost to appropriate health care. This article summarizes a presentation by Benjamin P. Linas, MD, MPH, at the IAS-USA continuing education program, Management of Hepatitis C Virus in the New Era: Small Molecules Bring Big Changes, held in Atlanta, Georgia, in September 2015.

Abstract: Noncommunicable conditions such as cardiovascular disease, hypertension, renal and bone diseases, and malignancies as well as infectious complications are an ongoing concern during the course of treated HIV disease. Research in this area continues to focus on the epidemiology and risk factors for these conditions, on identifying the contributions of HIV-related immunopathology to specific and collective end-organ diseases, and on evaluating interventions to prevent or reduce the morbidity associated with these conditions. Data presented at the 2016 Conference on Retroviruses and Opportunistic Infections provided new insights into all of these areas.

Abstract: Universal screening and frequent retesting are required to reduce the burden of sexually transmitted infections in the HIV-infected population. Dual treatment is available for gonorrhea, expedited partner therapy is effective and legal in most states, sexually transmitted infection rates are high in the context of preexposure prophylaxis, and there is a continuing rise in rates of syphilis, particularly early neurosyphilis. This article summarizes a presentation by Dana W. Dunne, MD, FACP, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in New York, New York, in March 2016.

Abstract: The 2016 Conference on Retroviruses and Opportunistic Infections continued to maintain balance in the representation of different areas of research related to HIV/AIDS. The basic science category encompasses research on viral reservoirs and HIV cure, on cellular factors regulating the interplay between virus and host, and on factors that influence viral pathogenicity. Basic research on factors that influence the interaction between the virus and the host cell continues to unearth surprises with the identification of a new host antiviral factor. Further, research into the mechanisms of viral persistence reveals that there is much to learn about how HIV-1 is able to persist in the face of antiviral suppression.

Abstract: At the 2016 Conference on Retroviruses and Opportunistic Infections (CROI) in Boston, Massachusetts, hepatitis C virus (HCV) infection remained a major theme in the context of HIV-associated liver disease, although other causes of liver disease garnered increased attention, including fatty liver disease, hepatitis B, and the impact of HIV disease itself on the liver. Although no data from phase III studies of HCV direct-acting antiviral (DAA) drugs for the treatment of HIV/HCV coinfection were presented at CROI 2016, a broad range of HCV DAA-related topics were presented, including accumulating experience with real-world performance of DAA-based regimens outside of clinical trials, drug interactions between DAA and antiretroviral drugs, treatment of acute HCV infection, and retreatment of individuals whose DAA-based regimens failed and those in whom resistance to DAA drugs emerged. A summary of select abstracts from CROI 2016 is presented, including discussion of clinical relevance where appropriate and areas for future research.

Abstract: From its beginning, the AIDS epidemic crystallized some of the major flaws of the American health care system. Most private health insurance was associated with employment, and job loss meant insurance loss. Private insurers refused new coverage for people with HIV infection. Medicaid, an important program for uninsured people with low income, was limited to only those in certain categories (eg, pregnant women or children), and although people who had progressed to AIDS were categorized as eligible (ie, "disabled"), those with early stage HIV disease were not. The Patient Protection and Affordable Care Act is a landmark change in health care law in general and for people with HIV infection in particular. Its provisions offer dramatic improvements in health coverage, although a Supreme Court ruling that limited the expansion of Medicaid poses ongoing problems in some states. This article summarizes a presentation by Timothy M. Westmoreland, JD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Washington, DC, in May 2015.

Abstract: The brain remains a major target for HIV infection and a site of potential complications for HIV-infected individuals. Emerging data presented at the 2016 Conference on Retroviruses and Opportunistic Infections suggest that during the early stages of infection, activated CD4+ cells may traffic the virus into the central nervous system (CNS). HIV is detectable in cells and tissues of the CNS in some individuals despite suppressive antiretroviral treatment. A potential source of cerebrospinal fluid HIV escape may be compartmentalized HIV replication within macrophage lineage cells. Virally infected cells can traffic out of the CNS and may have the potential to reseed the systemic compartment. Additional modifiers of HIV-associated neurocognitive disorder (HAND) were identified, including female sex and hepatic dysfunction. Large epidemiologic studies reported an elevated risk of stroke among HIV-infected individuals, related to traditional vascular risk factors, history of recreational drug use, and HIV measures (lower CD4+ cell nadir and higher viral load). Brain imaging may provide a noninvasive means for detecting early changes in the brain associated with HIV infection and may assist in prognosis of HAND. Some potential adjunctive therapies to standard antiretroviral therapy for HIV-infected individuals were considered.

Abstract: The 2016 Conference on Retroviruses and Opportunistic Infections highlighted exciting advances in antiretroviral therapy, including important data on investigational antiretroviral drugs and clinical trials. Clinical trials demonstrated benefits from a long-acting injectable coformulation given as maintenance therapy, examined intravenous and subcutaneous administration of a monoclonal antibody directed at the CD4 binding site of HIV-1, and provided novel data on tenofovir alafenamide. Several studies focused on the role of HIV drug resistance, including the significance of minority variants, transmitted drug resistance, use of resistance testing, and drug class-related resistance. Novel data on the HIV care continuum in low- and middle-income settings concentrated on differentiated HIV care delivery models and outcomes. Data on progress toward reaching World Health Organization 90-90-90 targets as well as outcomes related to expedited initiation of HIV treatment and adherence strategies were presented. Results from a trial in Malawi showed reduced rates of mother-to-child transmission among HIV-infected women who initiated antiretroviral therapy prior to pregnancy, and several studies highlighted the effect of antiretroviral therapy in pediatric populations. A special session was dedicated to the findings of studies of Ebola virus disease and treatment during the outbreak in West Africa.