Keynote Presentations
Keynote 1: HIV Cure - Where are we in 2021? Professor Sharon Lewin |
Despite the great success of antiviral therapy (ART), treatment is life-long for the majority of people with HIV. Antiviral treatment is simple and relatively cheap and close to 70% of people with HIV have access to treatment. However, ART is still not available or secure for many, drug resistance is common globally and there are emerging toxicities from some of the most potent antivirals. The main reason ART is unable to cure HIV infection is the persistence of long-lived proliferating latently infected cells and impaired clearance of HIV-infected cells.
Clinical strategies to achieve a cure are focused on targeting the virus to reduce the pool of infected cells and bolster immune control (reduce and control). This approach has been successful in animal models with some monkeys truly cured or in sustained remission off ART. These strategies have included a combination of TLR7 agonists, broadly neutralizing antibodies, vaccines and immunomodulating agents such as anti-PD1. Clinical trials of TLR7 agonists and anti-PD1 have recently been reported in humans with some promising findings.
Strategies to reduce the pool of infected cells have also included latency reversal agents that can enhance detection of a latently infected cell by increasing expression of viral proteins. A new class of latency reversing agents called SMAC mimetics has recently been reported and was highly effective in animal models. Human clinical trials are awaited. Advances in both ex vivo and in vivo gene therapy also looks promising using gene editing technologies such as CRISPR-Cas 9 to target and eliminate the provirus directly, modifying cells to make them resistant to HIV or enhancing production in vivo of neutralizing antibodies.
There are many challenges in HIV cure clinical research including the need for interruption of ART to detect efficacy, balancing the risk benefit ratio for participants, and ensuring safety of single agents prior to use of combinations. Active engagement of people living with HIV is critical to the success of these programs.
Keynote 2: LoveYourself Ph - Innovations and Self Care Project Dr. Ronivin Garcia Pagtakhan |
LoveYourselft Inc. (LY), is a community of volunteers which has been successful in reaching out to the key affected population of HIV and AIDS. It was founded in 2011 - with a mission of embracing and nurturing one's self-worth to inspire others to do the same and create ripples of positive change in the community and a vision of becoming a model community, empowering, and affirming the self-worth of youth and MSM in the Philippines.
LY has been the home of many innovative and new approaches to reach key populations such as Project Preppy (Pre-exposure Prophylaxis), LoveYourself Caravan/PBSR, Smart-Safe-Sexy Continuum of Care Approach Project (3S) and Introduction of the First Community Run Testing and Treatment Facility (4S) Project, #SafeSpaces Condom Promotion and Distribution Program Victoria by LoveYourself, the first Transgender Health and Wellness Community Center in the Philippines and most recently – introduction of HIV Self Screening (#SelfCare) in the Philippines to name a few.
LoveYourself Inc. is proud of its 8 LoveYourself Branded Community Centers, 2 Private Clinic and manages 15 Champion Community Centers safe space for young and working population who are engaging in risky behavior. For the LY community centers, having a cumulative rate of 150-200 clients daily with 12-14% reactive rate, the centers contribute to 42% of all the newly diagnosed PLHIVs reported in Metro Manila and 20% in the whole country for since 2016 to present proving that LY has a strong understanding of the Philippine context with regard to HIV and AIDS and key populations (MSM, TG, YKP and PWID). These efforts demonstrate a tremendous impact in bridging the gaps in the HIV continuum of care, with the objective of scaling up HIV testing and linking the newly diagnosed PLHIVs to treatment and care, eventually leading to reduced incidence of loss to follow up.
Since its launching, LY Anglo as the main treatment centers and the rest of the 6 as satellite centers has already diagnosed over 40,000 clients yearly. Of the total number of newly diagnosed PLHIVs, 7,300 were enrolled to LoveYourself Anglo treatment while the remaining were referred to RITM or other treatment hubs for enrolment making LY the second highest PLHIV clients enrolled facility. LoveYourself Anglo is currently being positioned as the first ever community run one stop shop – having prevention-to-treatment services. It aims to create a social enterprise-self-sustaining model.
While the geographical coverage of our LY branded HIV program is focused on Greater Metro Manila and Metro Cebu. LY was able to extend its coverage thru the establishment of the CHAMPION COMMUNITY CENTERS network with the aid of Global Fund ACER Grant. LY was able to establish 15 community centers from Luzon to Mindanao in partnership with Community Based Organizations (CBO) focusing on MSMs/TGs having them manage the community centers.
LY, introduced HIV self-testing in the Philippines in 2020 via a demonstration project called "Self Care". Using sure check self-testing kit, the program reached 2000 clients during its run and had a yield of 14% and linkage to care of 90%. With the support of Global fund thru PSFI and USAID – EPIC project, in 2021 – Self-Care is being scaled up to all the sites of Global Fund in the Philippines.
Keynote 3: Preparing for an Ageing HIV population A/Prof Reena Rajasuriar |
One in three PLWH in the Asia-Pacific region are expected to be over the age of 50 years by 2025. In addition to individuals with HIV living longer, new HIV diagnosis among older individuals is increasing, with a disproportionate number presenting late. Older PLWH experience a higher burden of multimorbidity including mental health compared to people without HIV of the same age. Additionally, the long-term health needs of older PLWH often include issues of pain, episodic/chronic disability, sleep disturbances and fatigue; all of which impact quality of life and extend beyond the capacity of typical HIV programs and health systems. This presentation will highlight the emerging issues around the care of ageing PLWH and outline opportunities to address them.
Keynote 4: HIV Stigma in Asia – What needs to be done Prof Adeeba Kamarulzaman |
HIV in Asia and the Pacific is characterised by concentrated and growing epidemics in key populations, particularly clients of sex workers and other sexual partners of key populations, people who inject drugs, and men who have sex with men. These individuals experience a high level of stigma and discrimination resulting in barriers in accessing HIV prevention and treatment services. Stigma experienced by a PLHIV is often multi-level, including self or internalised stigma, community and institutionalised particularly healthcare associated stigma. Successful interventions to address stigma will require a multi-faceted approach addressing each of these settings and the intersectionality of stigma experienced by PLHIV.
Local Context Presentations
Progress Update on the HIV Care Cascade in Singapore Dr Felicia Hong |
The current goal in the fight against HIV is ending acquired immune deficiency syndrome (AIDS) epidemic by 2030. To achieve this, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set up the 90-90-90 targets to reflect the cascade of HIV diagnosis, care and treatment (i.e. HIV care cascade). The targets are to have 90% of people living with HIV (PLHIV) knowing their HIV status, 90% of diagnosed PLHIV on sustained antiretroviral therapy (ART), and 90% of people on ART achieving viral load suppression, by 2020. The United Nations General Assembly High-Level Meeting on AIDS in June this year called on member states to achieve the 95-95-95 targets by 2025. This presentation updates on the Singapore's progress in achieving the targets.
HIV-1 transmitted drug resistance surveillance: Update on newly diagnosed cases in Singapore Dr Carmen Low |
The prevalence of drug resistance in individuals with newly diagnosed HIV infections reflects the extent to which drug-resistant strains of HIV are being transmitted and remains a priority for the monitoring and control of drug resistance to HIV medications. Through the surveillance of individuals without prior antiretroviral therapy to assess population-based transmitted drug resistance (TDR), this update will provide population characteristics and TDR prevalence on 746 residual specimens successfully sequenced between 2016 to 2020. The high prevalence of nonnucleoside reverse transcriptase inhibitors resistance indicates that efavirenz- or nevirapine-based regimen without prior resistance testing is not ideal in newly HIV infected individuals. Even though a low prevalence of protease inhibitors resistance and triple class resistance was observed, continuous monitoring of TDR to all drug classes is a necessity to implement effective strategies in primary antiretroviral therapy.
Impact of COVID-19 on HIV Testing in Singapore A/Prof Matthias Paul Toh |
COVID-19 and its associated complications are caused by the SARS-CoV-2 virus. First reported in Wuhan, China, on 31 December 2019, it spread rapidly across the whole world in the first 3 months of 2020 and led the World Health Organization (WHO) to declare a pandemic in March 2020.
Singapore detected its first imported case on 23 January 2020. Soon after, subsequent waves were detected within the local community and workers who live in large dormitories in Singapore.
Singapore sprang into action almost immediately to institute prevention and control measures and a slew of public health actions. These included intensive contact tracing and quarantine of close contacts, active case detection through testing and passive surveillance.
When cases started to rise rapidly in early April 2020, a "Circuit Breaker" was introduced for 4 weeks and extended to 8 weeks eventually. During this period, people who could work from home were not allowed to travel to office. Other than essential services, everyone had to stay at home. Fortunately, the "Circuit Breaker" bore fruit and incidence of COVID-19 dropped. This was followed by relaxation of public health measures and gradual reopening of the economy in phases.
Towards the end of 2020, the world was introduced to new SARS-CoV-2 variants of concerns (VOC) which were more transmissible and deadly. Today (September 2021), the Delta VOC is dominating the world. Singapore is still facing new waves of Delta VOC infections.
An important strategy in HIV prevention and control is early detection through testing and linkage of care to achieve U=U. Self-initiated testing of HIV has been gaining acceptance among MSM in Singapore. Anonymous testing of HIV is available at AfA Singapore and selected clinics across Singapore. In addition to anonymous testing, Singapore has established surveillance of HIV tests through the antenatal HIV Programme and Voluntary Opt-out Screening of HIV of inpatients in public hospitals.
This presentation provides an overview of the HIV screenings in Singapore and whether the COVID-19 pandemic has affected these programmes.
HIV care and treatment services in the time of COVID-19 A/Prof Sophia Archuleta |
The COVID-19 pandemic has impacted and disrupted
health care services across the globe. Maintaining the HIV care continuum has
required rapid, significant adaptations. In this session, we will examine
strategies implemented to ensure continued care and treatment in Singapore.
These included telehealth, de-linkage of medical consultations from dispensing
of antiretroviral therapy, and other means of reducing the frequency of clinic
or pharmacy visits. Changes occurred on the heels of national treatment
recommendations being adopted in late 2019 and concurrent to subsidies being
extended by the Ministry of Health for ART medications in 2020.
Presentation of Viral Suppression Data Dr Teh Yii Ean |
The COVID-19 pandemic has resulted in major disruption on the healthcare system and health service delivery worldwide. As countries went into lockdown and resources were diverted to combat the pandemic, prevention, testing and treatment services for PLHIV were inevitably affected.
In Singapore, the pandemic has accelerated the adoption of telemedicine and medication delivery services in healthcare institutions. This has ensured that access to care for PLHIV remain uninterrupted as far as possible.
We examine the impact this had on our patients, specifically to determine if the percentage of patients who had attained viral suppression had decreased in the last one year.
4th 90 – Living well with HIV and COVID-19 in Singapore Dr Dariusz Piotr Olszyna |
For people diagnosed and treated early, HIV is now a long-term condition. This has been achieved by widespread use of combination antiretroviral treatment which has led to high levels of viral suppression. However, people living with HIV (PLHIV) at all stages of their lives face unique health challenges. This presentation will focus on definition of so called "4th Ninety", proposed by some as the next global HIV goal. Both comorbidities and self-perceived quality of life among PLHIV will be discussed. The current pandemic has had a profound impact on delivery of health services and the speaker will discuss how it has affected PLHIVs. There have been various approaches proposed by several health experts on how to address the broader health needs of PLHIV beyond viral suppression; this will be covered in the last part of the presentation.
Recommendations and Guidelines
NHIVP Antiretroviral Treatment Recommendations – Updated Recommendations A/Prof Sophia Archuleta |
Since the advent of combination antiretroviral
therapy (ART), the mortality attributable to HIV infection has been reduced by
80%. Newer antiretroviral agents (ARVs) are highly efficacious, have minimal
side effects as compared to older drugs, and can be formulated as single-table
combination regimens with a reduced pill burden. Despite these advances, 680
000 people died of AIDS-related illnesses worldwide in 2020. As of end 2019, a
total of 8618 Singapore residents have been diagnosed with HIV infection, of
whom 2097 have died. The NHIVP developed
the “Recommendations for the Use of Antiretroviral Therapy (ART) in Adults
Living with HIV in Singapore” to guide physicians on the ART prescription based
on patients’ needs, tailored to local context with unique domestic
considerations. Reviewed and updated every two years, the purpose of the national recommendations is to enhance the care of people living with HIV, providing the best possible treatments to patients.
The latest review and key updates to the ART recommendations includes 1) Cost considerations, 2) Selection of ART, 3) Switching ART in the setting of virologic suppression and 4) Monitoring parameters in patients with HIV infection.
NHIVP Pre-Exposure Prophylaxis Guidance – Updated Guidance Dr Wong Chen Seong |
Pre-exposure prophylaxis (PrEP) is a supplementary preventive measure against HIV. In recent years, trials involving PrEP have suggested that it may also be considered in specific groups as an additional strategy to prevent HIV infection. Recognising that physicians in Singapore may wish to prescribe PrEP for their patients, the NHIVP convened a PrEP Workgroup in May 2019, to develop a "Guidance for the Prescription of HIV Pre-Exposure Prophylaxis (PrEP) in Singapore" for physicians on prescribing PrEP as an additional tool to prevent HIV infection. Updated every two years, the Workgroup's guidance this year is an updated adaptation of current major international guidelines on PrEP from the WHO, the US CDC, British HIV Association (BHIVA), the Australasian Society for HIV Medicine (ASHM), European AIDS Clinical Society and the Taiwan AIDS Society, as well as a previous local guideline created by the PrEP taskforce in April 2018.
The latest review and key updates to the PrEP guidance includes the following:
Special Clinical Scenarios pertaining to the safety of TDF/FTC, addition of TAF/FTC as potential regimen for cis-gender men who have sex with men and trans-gender women who have sex with men with indication of renal impairment and chronic HBV infection, and a new section on what to do in the setting of an indeterminate HIV antigen-antibody test.
Contraindications to PrEP in individuals with known impairment of renal function.
The appropriate use of TAF/FTC regimen
Serum creatinine and anti-HCV monitoring for key populations
HIV Testing Recommendations Dr Choy Chiaw Yee |
In recognition of the morbidity and mortality associated with HIV, the Joint United Nations Programme on HIV/AIDS (UNAIDS) aims to end the epidemic by setting and striving to achieve the ambitious 90-90-90 targets. However, Singapore is still not performing well in the first 90. Hence, the NHIVP developed this set of recommendations based on adaptations from the major international guidelines of the World Health Organisation (WHO) and the US Centers for Disease Control and Prevention (CDC) with the goals to:
1) Increase the uptake of HIV testing nationally;
2) Allow earlier detection and identification of individuals with HIV infection;
3) Facilitate timely linkage to clinical services; and
4) Reduce further transmission of HIV infection in Singapore by increasing testing and linking positive cases to care early.
Debate Motion
"This House believes that HIV self-testing should be rolled out in retail pharmacies" Proposition: Dr Stephanie Sutjipto, Dr Cherie Gan Opposition: Dr Alicia Ang, Dr Khoo Bo Yan |
HIV self-testing (HIVST) is where a person collects their own specimen and performs a HIV test in a private setting and interprets the result, either alone or with someone they trust. HIVST has the potential to increase testing, leading to earlier diagnosis with greater convenience for test users. Globally, studies have found a high acceptability of HIVST and the test results show a high sensitivity and specificity with minimal errors. On the other hand, concerns have been raised, which include lack of counselling, challenge of ensuring linkage to care, and potential for coercive use of self-testing devices and their accuracy. Hence in Singapore, HIVST are currently only allowed to be done in a clinic setting, with pros and cons on rolling out in retail pharmacies, which will be debated by our Senior Resident ID physicians at the Congress.
