Day 3 at CROI

Seattle sits on the extreme northwest of the USA and borders Canada to the north. It has a very busy port which is one of the busiest in the country and was named after a local Native American chief of the Duwamish and Squamish tribes. This explains its distinctly un-English name, same as other states whose names were derived from Native American names such as Minnesota, Saskatchewan, Mississippi and Nebraska. This happens to be the headquarters for Boeing, the airline manufacturer.

Yesterday, the opening plenary session featured Dorothy Mbori-Ngacha from UNICEF who talked about the elimination of mother-to-child transmission of HIV. She pointed out that 92% of all vertical infections are happening in sub-Saharan Africa whilst the same phenomenon has almost been eradicated in high-income countries. The global consensus to eliminate infection in children and improve the health of mothers and children in resource-poor settings is fraught with many challenges that need to be addressed before it can become reality. Some of these include recruitment and retention of pregnant women into care. Data from two studies in South Africa and Zambia presented at the conference revealed an unacceptably high rate of loss to follow-up by pregnant women. There is a dire shortage of skilled birth attendants in many resource-poor settings, and there is also a palpable lack of treatment of women for their own health. There are a number of challenges in implementing the WHO 2010 guidelines on PMTCT and infant feeding, and all these challenges have to be addressed before the set goal of 90% PMTCT coverage can be reached.

Session 34 looked at the risk of HIV-exposed and infected infants and children.

Some of the conclusions that came from the presentations:

· Patterns of growth, mortality and morbidity are higher in children exposed to HIV but uninfected than their unexposed counterparts. This group of children is most vulnerable when their mother’s CD4 count is high, or when she dies. HIV exposure in children is associated with immune abnormalities, and these might be caused by a number of factors, including exposure to maternal HIV, exposure to HAART, exposure to other maternal complications and lack of breastfeeding (for infants on exclusive formula). Prevention of HIV infection in adults is key to preventing such complications.

· During the early years of the pandemic, the only testing available for infants was the ELISA assay, and this was only done at 18 months of birth . In 2004, the WHO then settled for a DNA PCR (polymerase chain-reaction) test that could be done at 6 weeks of birth. A number or problems still persisted with laboratories having different capacities; some infants were not tested, poor turn-around of results and initiation of positive infants on HAART. Newer laboratory-based HIV testing technologies and point-of-care devices are now in the offing, and these can perform tests earlier than the current 6-week threshold.

· A controversial presentation looked at the controversies and consequences of initiating HIV+ infants. Managing HIV infection is more challenging due to high viral loads, limited drug options, poor palatability of medicines and reliance on caregivers. As an answer to the unsustainability of life-long ART, Andrew Prendergrast proposed treatment interruptions, and this suggestion met with strong negative reactions from the audience.

Other sessions were as follows:

1. Neurological issues in HIV infection

2. Treatment in Resource-Limited settings: Impact and Challenges

3. Advances in Vaccines and Immune-Based Therapies

4. Drug resistance

5. Aging and Neurocognitive Impairment

6. Elite Controllers (also known as long-term non-progressors)

7. Viral Latency and Reservoirs

8. Metabolic and Cardiovascular Complications