Announcer

Welcome to the Academy Exchange, HIV Today and tomorrow. In this podcast, we discuss the latest advances in HIV prevention care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us. 

Bruce

Welcome to this bonus episode of the Academy Exchange. I'm your host, Bruce Packett, Executive Director of the American Academy of HIV Medicine, and today we have a special episode as we dive into the highlights and key take home messages from the 12th International Aid Society Conference on HIV

Science, which took place in the beautiful city of Brisbane, Australia, from July 23rd to July 26th.

At this renowned international scientific conference, leading medical experts, researchers and clinicians from across the globe gather to share their groundbreaking findings and advancements in HIV research and treatment. Along with the Conference on Retroviruses and Opportunistic Infections, IAS is one of the two biggest scientific conferences on HIV and related conditions. 

Today, we're privileged to have not one but two distinguished medical doctors who were at the forefront of this event, bringing you their invaluable insights directly from the conference floor, and what we hope to accomplish today is to really try to underscore the key clinical takeaways from some of the research that was presented at the conference. In other words, what a busy providers need to know about what's coming out of IAS and what can they take with them back to their respective clinics. 

Our first guest today is Dr. William R Short, who is an HIV researcher and clinician who's been actively involved in studies that have evolved our understanding of HIV and its management. Dr. Short is associate Professor of Medicine with a secondary appointment in Obstetrics and Gynecology at the Perelman School of Medicine, University of Pennsylvania. Dr. Short graduated with his Doctor of Medicine degree from Hahnemann University. Subsequently, he completed an internship, residency and chief residency in Internal Medicine, followed by an ID fellowship at the MCP Hahnemann University. Locally, Dr. Short serves as the associate director of the Penn HIV Clinical Trials Unit and the co-director of the clinical core Penn's Center for AIDS Research. He maintains two active practices one in the Penn Community Practice and the second one in the Helen O. Dickens OBGYN Clinic, where he's involved in the care of pregnant women living with HIV. Dr. Short again will be sharing key clinical updates and exciting guidance to help providers manage HIV and related conditions in their clinic. Dr. Short, welcome. 

Dr. Short

Thank you, nice to be here.

Bruce

Of course, along with Dr. Short today, we also have Dr. Laura Armas, who is the founder and CEO of Human Centered Consulting and CARE. Dr. Armas is providing care to persons living with HIV in academic community based organizations and private practice during her 25 year career. She is a former chief medical officer of CAN Community Health, associate professor at the University of Florida and medical director for a regional ATC. She currently serves on the Academy Board of Directors. Dr. Armas, welcome to you as well. Thanks for being here. 

Dr. Armas

Thank you Bruce, it's a pleasure to be here.

Bruce

Absolutely, and Dr. Short, I neglected to mention that you are, in fact, the chairman of the Board of the American Academy of Medicine, another important part of your bio. 

Okay, so you were both at the IAC conference that took place last week in Brisbane.

I want to start just by getting your general impressions of IAS this year. We'll get into some of the specific research and guidance that we want to highlight today, but what can you say about the content of the conference overall this year, was 2023 a relatively big year for HIV science? And what were the main themes at the conference this year? Dr. Armas, why don't we start with your general reactions and impressions? 

Dr. Armas

Okay, so thank you, Bruce. I think there were several groundbreaking results, like we're going to discuss very shortly. But also it was a conference that was filled up with hope for a cure. Several seminal studies on broadly acting, neutralizing antibodies and in other studies, vaccines and long acting antiretrovirals.

A lot of the conference was focused on the continuum of care and the evolution of primary care from being just managing people to survive the virus, to now managing the comorbidities that come along with survival from the virus. I think it was very exciting and a lot of enthusiasm globally. 

Bruce

Really helpful background there. Dr. Short, over to you. What were your impressions? 

Dr. Short

Yeah, first of all, I thought it was great. First, you know, once you get through that very long flight to get to Australia, first of all, just taking in the beauty of Australia and really understanding some of the things that happen, that are happening, with HIV on the other side of the world, so to speak. So, I thought that was really important because we don't really talk often about Australia and sort of what happens there, but it's one of the places that is really close to eliminating HIV. You know, the reaching the goals. So I thought that was wonderful, beautiful place to be. But I thought there was a lot of interesting research that came out of this and I think, you know, Laura really hit upon it. You know, obviously there's always hopes for a HIV cure. Where we really want to go, but a lot about long acting technologies and not only just the injectable that we have, but really is, how can we get away from for those who don't want to take pills to injectables and let's look beyond injectables about giving an infusion and, you know, try to make this an every six month, every one year type of treatment. So to deal with a lot of the barriers which we'll talk about.

I think the other thing that was really striking at this conference is, as is at a lot of the international conferences, there's a lot of activism that goes on. So in the middle of a plenary session, you may have people who are very passionate about key topics, and I think we're going to get into it next where, you know, zero transmission was one of the first ones, where people started at the top of the escalator from three stories or two stories up, and you heard them chanting and they walked across the stage into plenary, very peaceful and got really the crowd excited and motivated and then we continued on with the topic. 

So that's one of the things I really love about the international conferences. You just have so many different types of individuals who are there, and you just walk away no matter how far and how jetlagged you are, with such a wonderful feeling when you leave the international conferences.

Bruce

Let's get into some of those highlights, starting with Dr. Armas, can you talk a bit about the new W.H.O. consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring that was unveiled at IAS. And I'm hoping related to that, you can touch on what Bill just mentioned around this, new zero transmission, the studies for virally suppressed patients, undetectable equals and untransmittable, and what it means towards getting to zero new transmissions.

What can providers here do in the states, Dr. Armas, in their respective clinics with regard to this guidance around U=U, low-level viremia and transmission risk. 

Dr. Armas

So, thank you Bruce. That was one of the most exciting sessions. It was just right before the opening session that W.H.O. hosted a satellite session to present the recently published consolidated guidelines. These guidelines are a little different than the traditional, they have a public health, person-centered approach, and this document is a structure along the continuum of care includes recommendations for testing to management of co-infections and comorbidities. 

They also play for people living with HIV in communities at risk at the center of the HIV response and they call to achieve the goal of 95% of the people at risk know their status, 95% of those who are positive, we initiate treatment and those receiving treatment, 95% should be undetectable or suppressed by 2030. 

So if you remember, the previous goals for 2020 were 90-90-90, well they increased that goal and as we mentioned, Australia this early, is set to be meeting those goals already. So it is very exciting, it is achievable and we can do it. Also, the primary audience for these guidelines are low and middle income countries. It is very important for our providers in the United States who practice in our long resource settings in the United States because they face several social determinants of health similar to these countries. 

Another thing that you just touch, is it was this issue of, really strong statement, U=U, undetectable = untransmittable. They discuss the results of a systematic review by Broyles that was published in The Lancet with three studies that showed no transmission when people living with HIV had a viral load of less than 200 and most transmissions occur when the viral load was between 30,000 to 750,000. 

Across four perspective studies, there were 323 transmission events, but none with people living with HIV that were suppressed. 

In among all the studies, only two cases when people living with HIV transmitted the virus and they had a viral load that was around 750 to 850. So in reality what that translates to is, if you're undetectable, there is zero risk for transmission.

So I think our provider's can start telling that to our patients and motivate them to get to undetectable because then there is no risk for them to do sexual transmission. If they are suppressed, there is almost zero negligible. But you know the legal aspects of it, so they just recommend don’t say zero but it’s close to zero and when people are unsuppressed, that's when there is a high risk of transmission. 

They also talk about the majority of people who know their status are already in care and they're already receiving treatment and they are either suppressed or undetectable. So it's very little the risk of transmission for those who are in care, but for those who are not in care particularly the undiagnosed are the ones having a risk.

Unfortunately, there was no information on injection drug use transmissibility, but that's something W.H.O is working along with other priorities regarding STIs.

Bruce 

It's a really important message because what we're talking about is, is really just strengthening that U=U messaging, like you said, undetectable equals and untransmittable and the science is continuing to strengthen that message. Thank you for sharing that.

Did you want to add anything to that? Dr. Short?

Dr. Short

 Yeah, I don't want to really repeat what she said. I think what you know, everything was right there. But I think first message is we as providers and as a community, we need to get this messaging out. There are still plenty of people who are unaware of the original messaging that U=U. That is so important to get out for people for many reasons and I think you highlighted it, one of its most important and powerful opportunity to get rid of stigma, you know, and help really destigmatize this condition. 

The other thing is, you know, it's encouraging people to continue to take their medications. Right?

Whether it's pills or injectables to get that level down. So that's the first point but I think what's really important is when I have patients who call and say, you know, oh my God, my viral loads 87, I don't want to transmit because those who know and are aware there really tuned into this now and we again we reinforce undetectable is not what the assay is less than 50, it's 200 but now we can say it's less than 1,000.

And I really love the fact that the Lancet article sort of coincided with the W.H.O. guidance that was issued around U=U. So again, I think it's really about getting that message out to everyone about the new level and what is considered undetectable. 

Dr.Armas

And if I might add, for those who are like us, are involved in activism, I think this is very important for decriminalizing HIV.

Bruce

Absolutely, great point. Dr. Short, I know you were heavily involved in the REPRIEVE study that was discussed at IAS that looked at statins for cardiovascular disease prevention and people with HIV. I'm hoping you could tell us what did this study reveal and specifically what can clinicians do, practically speaking, to implement this research into their regular HIV clinical management?

Dr. Short

Sure. I do think and not just because I was involved in it, I think this was one of the most highly anticipated and really one of the greatest presentations that was at this conference. And, I could tell you the room was probably one of the smallest rooms we had, and it was just overflowing with people.

So the REPRIEVE study was designed a few years ago with really the major question being ask is, you know, can a statin, and for those who don't know statin, statins are a type of medication that we typically think of to lower cholesterol, specifically LDL cholesterol. But really some of the other properties, that's their primary effect is cholesterol and LDL reduction, but some of the other properties we see is that it helps to lower maybe immune activation, inflammation, things that we know are unaffected by antiretrovirals, right, because despite given antiretroviral therapy, there still remains immune activation and chronic inflammation in people living with HIV.

So the question was, if we gave a statin to a person who did not meet criteria for a statin, and that's really key in this study because it would be unethical to give someone placebo because this trial basically evaluatedpitavastatin, which is the statin that was used in the trial to placebo. So someone had a risk, right? You couldn't say I'm going to randomized to a placebo. So these were people that were living with HIV, taking antiretroviral so you get rid of that effect that could, we know leads to higher incidence of myocardial infarction and they had low to moderate risk and this was done through the ASCVD risk calculator and that was their prime question. They were randomized, you know, to either get the statin or the placebo. 

This trial enrolled almost 8,000 participants and its primary endpoint was really the time to the first major adverse cardiac event and that could be a cardiac death, a myocardial infarction, a stroke, a TIA, some type of peripheral arterial disease and you know, one thing I will say about the study, it was also very difficult. This was done through times of COVID. So, you know, making sure everyone was in, making sure everyone got their statin. So there was a lot of things that really we should be proud of with the study that actually happened. And so what the study showed is and the study was stopped early by the Data Safety Monitoring Board when they evaluated and showed that to prevent the primary major adverse cardiac event, there was a 35% decrease relative to placebo in that primary endpoint. And also when you look at death or mortality, there was a 21% decrease versus placebo. So that study was then stopped and then everyone was taken off study drug and here we are now with the results. 

What I think people left with from not only the study but also similar to what we just talked about earlier, the publication came out in the New England Journal and there's still lots of pieces to go through. There's a lot of things to highlight about this, is that when you look at what the statin did, it was really consistent across all major subgroups, including LDL age, sex, race, CD4 count, ART duration. And really it was unbelievable that no matter which way you sliced it or diced it, you still did see a reduction in that first major cardiac event.

So the big question is, Bruce, and I think this is where we don't know is, what does that mean for everyone? Obviously, we have a study that showed a very significant result as well as a mortality benefit. And then the question is, do we recommend the statin for all people living with HIV? And everybody has strong opinions about that. 

One of the latter parts of the analysis was done where they basically looked at whether or not you had the cardiac event and whether it was by ASCVD risk score and they broke it down by zero to less than 2.5, 2.5 to less than 5, 5 to 10 and greater than ten. And obviously the higher you go, the higher your risk you are. And what they saw is that somewhere in that moderate, moderate to high risk category, that's where and the way we look at it, as we look at the number needed to treat, it met that number needed to treat, which is really where we can say that it has a benefit. Obviously, this has a lot of work to be done and we really need a group, a guidelines panel, and the question is which guideline panel? And I think that's going to be interesting. You know, is it going to be the Department of Health and Human Services guideline panel? They make recommendations on antiretrovirals, not statins. Is it going to be a cardiovascular group? It's a cardiovascular guideline, but I think all of us are waiting patiently for this. You know, a lot of people, including myself, have already, especially people that were on the study, have started to put patients on statins.

Some of the other things that I think are important because we know statins like any other drug are not benign. You know, statins have side effects that you have to watch out for and the big ones we think about are sort of myopathies, do people have, you know, muscle aches and pains? There was no difference, it was the same rate you would see in the population not impacted or impacted by HIV. And the other thing was the risk of diabetes, and there was a modest risk of diabetes, which again you see in other statins. So I think the big question remains is what are the guidelines going to say for us, clinically? You know, it looks like we are going to start recommending statins for a lot of people. But I do encourage you, if you have not had a chance, there's a lot of material to digest and, you know, as Steve Grinspoon said at the microphone, there's going to be data coming out for years, there's so much data that they collected. 

We're really going to get a lot of the answers we need about cardiovascular prevention in people living with HIV. So very exciting presentation and again, I encourage you to listen to the presentation and read the publication in the New England Journal. 

Bruce

Yeah, that's obviously really important and thanks for the thorough explanation while I have you speaking Dr. Short, I know you wanted to touch also on the use of Doxycycline as opposed to post-exposure prophylaxis or PEP for STIs, which was discussed at the conference.  What do providers need to know about this STI prevention method?

Dr. Short

There was a great session on Doxy PEP. I think we've seen from other conferences the clinical trials around it, and I think everyone's sort of doing their own thing around this. You know, we tend to look at certain groups of individuals, specifically men who have sex with men and transgender women and we decide who should get it based on STIs and I thought the way this summary was given after this presentation and what they recommended is a few things. 

So who should get it? So men who have sex with men and transgender women with or without HIV and I love the fact that they preface that to say, like, you know, there are people who are taking pre-exposure prophylaxis, you should get it. And in that, who should get it, so sex with casual partners where there's not regular use of condoms. If you've had more than one to two STIs in the last 12 months and this number has been floated around by different groups of individuals, you know, what is sort of your surrogate for who should get Doxy PEP. Also you want to make sure they've been tested for gonorrhea, chlamydia, syphilis about a week before starting post-exposure prophylaxis and then making sure they don't have allergies. And I also think for myself when I prescribe it, because I do prescribe it in the clinic, is making sure people understand the side effects of Doxycycline, that was not covered in here. They talked a little bit about allergies, but I think it's really important to remind people, and especially we're in the summer months here in the Northeast, making sure people instructing them that there's photosensitivity, making sure you take it with a full glass of water and remain upright for an hour.

If anyone's ever had that pill come back and sit on esophagus and cause pill esophagitis you will know and you will never want to take the drug again. And now you're taking two doses, 200 milligrams, which I'll get to in a second. And then also, you know, making sure you don't have any drugs that interact with it. 

So that's the first piece and the second was what about the prescription? And this was the first I heard this. So we know the dose is 200 milligrams. You take it 24 hours, but no later than 72 hours following your exposure. What I like what they did is they talked about the forms and many of us have gone into our electronic recording and you hit Doxycycline and you see monohydrate or hyclate, you're like, Where do I go?

So it's interesting here they recommended that you use the monohydrate form for less GI side effects, which I had never heard. So I thought that was really great to say. Use that monohydrate form, again making sure you take it with food and water, and again I give you the time. The other thing they added in here is no more than 1 to 3 times a week. Again, something when I prescribe, I just sort of talk about, but I never really gave them a frequency. Also, keep in mind that these are not official guidelines, these are recommendations. And I really think it's so important that. But I felt like for the first time I had a framework. The last part I think is really key and I really love this, is how do you monitor doxy PEP?

One of the things I have as an infectious disease provider is, I worry about overuse of antibiotics because I know overuse leads to resistance and so what about Doxy? You know, Doxy is a wonderful treatment. And it's sometimes a treatment for a lot of different things and things where we don't have other options. So they recommend doing STI testing every three months, obviously continuing assessing the safety, all the things we talked about. However, if you had an STI where you needed Doxycycline for treatment and we know typically that chlamydia infections and also syphilis, if you cannot get Bicillin and if you maybe have an allergy or some other reason why you would use Doxycycline. If you get treatment with Doxycycline for an STI that you should do a test to cure. Because again, we're worried about resistance and then obviously if that is the case, you want to report it to the public health department. So, I thought that part was really helpful and I really look forward to guidance that's going to come out from others. But I really love the summary of things that they recommended for us because before it was just kind of like we all were doing our own little thing. And you know, patients now are actually, I have to say, patients are calling me office, maybe I haven't seen them in a while and saying, Hey, I heard about this Doxy PEP, I would like to get on it. So, I do think there's a lot of key points in what I just said that are worthwhile until we have official guidance from somebody that will provide that to us.

Bruce

Now, going back to Dr. Armas, one of the studies at IAS you were following was the ANCHOR study and the conversation around HPV, self-sampling, anal cancer risks and so on. What do you think providers need to know about this study presented at the conference? 

Dr. Armas

Just prior to the conference, we had a pre-meeting on HPV related cancers in this first time that gynecological experts, as well as the experts on the field of anal HPV were together in giving, could join, recommendations to avoid these debilitating cancers. 

But specifically for anal HPV, number one, the best way to reduce the incidence of HPV is gender-neutral vaccination, vaccinate. Especially those living with HIV or at risk for HIV. Ideally, should be done in infancy during the childhood of your patients but as you know, not everybody gets vaccinated. 

Then we talk about the screening and there are several forms of screening. There is anal cytology. There is a high risk HPV DNA testing, as well as co-testing, meaning doing both of them. And they are different in the sensitivity and specificity. What they presented at length, it was the efficacy and the ability to expand access and uptake to HPV testing by doing self-sampling and they were recommending it specifically for cervical cancer. But one the experts on cancer, Dr. Polaski here at UCSF, they said there's no issue why they should not be doing cell therapy.

HPV, high risk, particularly strains 16 and 18 are correlated with anal cancer in dysplasia, particularly in MSM. About almost 30% of them are going to have HPV 16 and 75% are going to have any other kind of high risk HPV. And men who have sex with women, the incidence is lower, 8.7% for HPV 16 and in women is 17%. 36% of these women have high-grade dysplasia and before you do any testing, you need to identify referral sources for treatment. That's something that was very well expressed and suggested recommended actually, that you need to have a referral source, someone that is proficient in and culturally humble to take care of this patient population and do a high resolution endoscopy or whatever procedure. Early in my career I had bad experiences by being too excited, screening for anal pap smears and not having the resources and it creates a lot of anxiety.

When it comes to the anal cancer risk, back last year, I believe 2021, they published a risk scale in which they show that MSM with HIV more than 45 years of age are the ones who have the highest risk, especially if they're over 60. That is followed by women living with HIV who had a history of gynecological pre-cancers, particularly those of the vulva. And follow in the risk categories, those who are non-HIV immunocompromised. Those are the people who have the highest risk. But across the board, people living with HIV may often have higher risk than the non-immunocompromised.

In the ANCHOR study. What they study, it was number one, what was the incidence of high grade dysplasia in cancer at screening in the screen? In the screening, about almost 11,000, 10,723 people living with HIV and of those, 53.3% of men have anal high-grade dysplasia, 47.2% of women will have it, and 67.1% of transgender individuals had anal high-grade dysplasia. Only 17 individuals, which is .1- .2% of the individuals, were diagnosed with anal cancer. But what they also saw it was that if they treated either with infrared coagulation or with hyfrectation, which is electric coagulation, they found 57% reduction in progression to anal cancer.

So that was very significant. The cancer incidence in the treatment arm was 173 people out of 100,000 person years, a follow up compared with 402 over 100,000 person years in the non-treatment group. So it is very important, Number one, we vaccinate. Number two, we screen, either with cytology, with high risk HPV or doing co-testing and they are working on some recommendations that are currently being reviewed by the CDC and hopefully by the end of the year we will have some published guidelines, because they are a little complex to be described orally and refer for treatment. If they get treated, they will they will prevent this cancer that creates a lot of stress, a lot of function of not just discomfort, impotence, but issues with sexual activity as well. So I was very excited to see these results.

I was peripherally involved with the ANCHOR study and one of my previous jobs. So it was very exciting to see the results of this long awaited study. 

Bruce

Yeah, that's very exciting. Thanks for that explanation. Our last highlight that we wanted to cover from the conference is around the JABS 48 week study, which looked at long acting injectable ARV agents in patients with complex needs. I'm happy to hear both of your thoughts on this, but let's go ahead and start with Dr. Short. What can you tell providers who are listening what this means practically speaking for their clinics and patients?

Dr. Short 

Sure. I think first before I get into the study, you know, it's very nice at IAS conference, typically what happens, a lot of publications come out and similar to what we talked about earlier with REPRIEVE and the W.H.O. statement, there was also a supplement that came out from the journal of the International Aid Society, and it was specifically looking at long acting and extended delivery technologies. And so it's also a July edition and the title is Advancing Use of Long Acting in Extended Delivery, HIV Prevention and Treatment Regimens and it really covers a variety of topics that I think are important.

And as I mentioned in the beginning, you know, this was one of the highlights, one of the opening plenaries was about long acting and sort of long acting, meaning anything that's not daily. So this study in particular, we go to what JABS really looked at, and I love it because, you know, we think of the guidelines, the guidelines, say to us, people who are candidates for long acting, cab/rilpivirine are those who are suppressed. But we all know, we take care of lots of patients who are not taking their medication for a whole host of reasons. And when you go to maybe use this drug, obviously we always get kickback maybe from the pharmaceutical saying no, you can't get that the person is not virally suppressed, I see that in my clinic. But more and more data is coming out now that this may be the best thing for patients, giving them an injection so they don't have to have that pill, which is a daily reminder of their HIV status or they have to take it every day.

So there was some initial data that many of you have seen from Monica Gandhi, from UCSF and her clinic population. That was a vulnerable population with complex needs. Well, this was looking at a very similar population. These were living in Western Australia and just like Monica's study, these had complex medical needs, social vulnerability and historically they were non-adherent. There was only about 60 patients, but when you look, there was a whole series of factors in going down. There was social isolation, mental health, alcohol, drug use, financial instability, methamphetamine use, cognitive issues, polypharmacy, all of that. And again, what they found was that giving them a long acting

Injectable, to me, what the most important part was that at week 48, 98% of them had an HIV one RNA viral load, less than 50 copies, and there was only one that had a viral load of 55 and there were no virologic failures and for the purpose of this study it was greater than 200. 

I think these are really great, but I think they have to be done carefully because one of the things you worry about with using the injectable is you have obviously two drugs, two class of drugs, you have an integrase inhibitor and you have a NNRTI. And we know from a lot of people's past experience they may have been exposed to NNRTIs in the past and depending on which NNRTI you were on and maybe failed, you may develop resistance that's going to impact that. So you want to be very cautious in going through patient's history. You know, you don't want to say, here's a patient in front of me. They're poorly adherent because if they're poorly adherent, maybe they were before and develop some resistance. And then you give them this drug and they blow through and they get now, not only NNRTI resistance, but integrase resistance. So I do say that this has to be done carefully, I just think it's another option because we do have patients that need other options than a daily pill.

If someone is living on the street, maybe they can't take a pill every day. Someone who lives with someone who is unaware of their HIV status. There may be abuse, there may be all types of things going on in their home and the pills the last thing they think about. I've had patients who have had to hide pills under their beds and they're afraid someone's going to look at it and we know people have access to the Internet, all you have to do is plug in the word for the new drug and that tells you exactly what it's for. So I do like these studies, and I think that we're hearing more and more about them and really a large focus of the conference and satellite symposiums are really all about long acting technologies and really we're starting to see an explosion of this, right. Many places are getting approval of these long acting and it's very exciting for a lot of patients. And I know in my clinic population when I have a group of people who say to me, my life is never been the same since I started this injection, I never have to think about HIV. I can go and come and not have to worry about carrying the pill with me. So it really has revolutionized care. 

Now, not for everyone. I have plenty of people who say I love you, but I don't want to come in and see you every two months. Talk to me one more every six months, every year. I think that's where the field is heading. What's the next step in long acting technologies? And I think that's what we're going to see in the years to come, is how do we take this from every two months to every six months, every three months? And there are other technologies being investigated, looking at using recombinant what's called Hyaluronidase to increase the form and get a D performance your muscles. So maybe you can extend that to every three every four months. So lots of different new things happening, exciting in terms of long acting antiretroviral therapy. So very exciting times.

Bruce

Definitely exciting. We'll look for those evolutions. Dr. Armas, anything you'd like to add from your perspective about the JAB study or long acting agents?

Dr. Armas 

Internalize stigma is one of the major drivers of non-adherence, particularly with women. So these medications, I have seen it with women just being injected, they're so used to having their Depo-Provera. This has been so liberating to many of them. And that's why the W.H.O. and other organizations are recommending for us to use it, and particularly with PREP, it's going to be it is a game changer.

 I do agree that we need to be very careful about monitoring these patients, but sometimes just the fact that they're undetectable and again, don't mean to be repetitive, but just getting them excited about, U=U and getting them there might be an acting motivator for them to stay in care. This is a crucial part of the HIV prevention strategy to get them to undetectable.

Bruce

Absolutely right. Well, this has been a really great practical conference recap. Thank you both for joining me today and sharing your impressions of last week's HIV scientific update in Australia and some of the major themes and studies there in. We learned a lot of good information today that represents the latest research and recommendations, and we hope that health care providers who are listening will be able to concretely incorporate this information into their practices where appropriate.

So I want to thank you both again for your time today. 

Dr. Short

Thank you. 

Dr. Armas

Thank you.

Bruce

Bye, bye. Take care.