Transcript A bit if everything!

IAS feedback
Laura Waters
Consultant in HIV and GU Medicine
Mortimer Market Centre
Disclosure
Er….awks
Even more awks….my crushes
Content
• Treatment
– Benefits
• Medical (START)
• Transmission (PARTNER)
– Coverage
– Test and treat
• Drugs
– New data
– New strategies
BENEFITS OF ART
Strategic Timing of Antiretroviral Treatment (START) Trial
START
• International RCT of immediate vs deferred ART
• The primary composite endpoint = a serious AIDS event, serious non-AIDS event, or
death from any cause
HIV-positive ART-naïve individuals with CD4 cell count >500
cells/mm3
Characteristic
N=4,685
Age (year)*
36 (29, 44)
Female, n (%)
1257 (27)
Race, n (%)
Deferred ART Group
Immediate ART Group
Initiate ART immediately
following randomisation
n=2,326
Defer ART until CD4 cell
count declines to
<350 cells/mm3 or AIDS
develops
n=2,359
White
2086 (45)
Black
1,410 (30)
Time since HIV diagnosis
(year)*
1.0 (0.4, 3.1)
CD4 cell count (cells/mm3)*
651 (584–765)
Baseline HIV-RNA
(copies/mL)*
12,759 (3,019–43,391)
TDF usage
89% in both groups
* Median (IQR)
•
On 15 May 2015, at a planned interim review, DSMB recommended participants in the deferred
arm not already on ART should be offered ART and follow-up should continue with all subjects
on therapy. LFU (last contact >10/12) 4% immediate & 5% deferred
Lungren, IAS Vancouver Canada 2015, Oral MOSY03
7
START: Primary results
(95% confidence interval
[CI], 0.30 to 0.62; P<0.001)
n=2,359
n=2,326
1. Lundgren D, et al. IAS 2015. Vancouver, CAN. Oral # MOSY03;
2. Lundgren D, et al. NEJM 2015 Published Epub ahead of print July 20, 2015 DOI: 10.1056/NEJMoa1506816
PARTNER
• European observational study
• Serodifferent couples (where HIV+ partner
undetectable on treatment) reporting CLSI
• Initial results presented CROI 2014
• Final results IAS 2016 and just published!
Final results
• 888 couples (340 MSM, 548 heterosexual)
• Couples had already been having CLSI for an average
of 2 years before entering the study
• During study there were 58,213 condomless sex acts
• 20% of the reported anal sex was in heterosexuals
• ZERO TRANSMISSIONS FROM PRIMARY PARTNERS!!
• 11 transmission from other partners
Caveats
• Confidence intervals
– Narrower than at 2014 analysis
– 0.3% overall, 1% for anal sex in MSM where HIV+ top
– Higher estimated risk if +VL: 2.23% overall, 2.7% in MSM
• Author conclusion:
– We can fairly safely say that the chance of transmission
form a virally suppressed HIV+ person during heterosexual
sex is negligible
– However, we need to collect more data on gay me before
saying this with the same degree of certainty
Caveats (from accompanying editorial)
• Individuals in ‘stable’ relationships may not reflect all
PLWH
– Consistent with findings from some PreP studies eg.
PARTNERS PrEP vs VOICE & TDF-2
•
•
•
•
HIV+ participants had been on ART for average 7.5Y
High self-reported adherence
High levels STI screening + advice
HIV- partners were still HIV- despite 2 years CLSI
prior to study entry
COVERAGE: 90-90-90
UNAIDS: 90-90-90
90 90 90
%%
Diagnosed
Lazarus JV et al. BMC Med. 2016; 14: 94.
%
%
On treatment
%
Undetectable
Test & treat: ANRS 12249
• First major study of test & treat approach
• KwaZulu-Natal where 30% are HIV+ (highest in SA)
• Cluster RCT
– Each cluster = geographical area of about 1000 residents
– 11 intervention clusters, 11 controls
• Intervention
– Whole population over age 16 in both groups offered
home-based HIV testing every 6/12
– Intervention clusters offered immediate ART
ANRS 12249 TasP trial
 Objective: To evaluate the effect of early ART, initated
irrespective of CD4 count criteria, on HIV incidence in the
general population in the same setting
• Design: Cluster-randomized trial (Iwuji et al. Trials 2013; OrneGliemann et al. BMC Public Health 2015)
6-monthly rounds of home-based HIV-testing
Intervention
Control
Treat all HIV+ individuals
regardless of CD4 count
and clinical stage
Treat all HIV+ individuals
according to South African guidelines
Phase 1
2012
(≤350 CD4, WHO stage 3 or 4
until Dec 2014, ≤500 since Jan 2015)
Phase 2
2014
2016
23
Results
•
•
•
•
28,153 in study population, average age 30, 63% F
31% already living with HIV (34% of those on ART)
88% tested at least once
If diagnosed HIV+ linkage poor:
–
–
–
–
28% had attended ART clinic by 3 months
36% by 6 months
47% by 12 months
ALMOST IDENTICAL IN THE TWO GROUPS
ANRS 12249 TasP - Estimated cascade of care
UNAIDS target
TasP trial (1st January 2016)
Control
Intervention
25
New HIV infections
• 2.21% per year (2.13% intervention clusters vs 2.27%
controls)
• Further analyses required to explain lack of
engagement in care
– Was the intervention sufficient?
– Community attitudes & stigma?
SEARCH Study
• Ongoing cluster randomized trial to evaluate an HIV
“test and treat” strategy
– 32 communities; ~10,000 residents in each
• 12 Kenya, 10 Western Uganda, 10 Eastern Uganda
• Intervention:
1. Annual community-based HIV & multi disease testing
2. Universal ART eligibility with streamlined care
NCT:01864603
SEARCH Testing Intervention: Annual
Community-Based Testing
• Goal: >90% HIV testing
• Approach:
– Community based, out of facility
– Multi-disease: HIV, DM, HT,
malaria
– “Collapse the Cascade”immediate link to public health
services
1. Census/Mobilization
2. Two week Health Fair
3. Home testing for
non-participants
Chamie, Lancet HIV 2016
SEARCH Treatment Intervention: Universal
Streamlined ART Delivery
1. Efficient Visits for Patients and Staff
2. Patient-centered approach to care
• ART start at first clinic visit as indicated
•
Welcoming environment
•
Fostering trust, connection, and a sense
of investment in the patient
•
Flexible clinic hours
•
Tiered Tracking
•
Multi-disease chronic care model
• Triage by nurse or other extender at
all follow-up visits
• Clinic visits and ART dispensation every
3 months rather than every 1-2 months
5. Viral Load Counseling
3. Telephone hotline
4. Appointment
access for patients
reminders by phone/SMS
• Easy triage of medical
questions
• One week to few days in
advance
• Appointment/scheduling
logistics for retention
• Retention tool
• Structured format for
discussion of undetectable and
detectable results
Jain et al., AIDS, 2014
Kwarisiima et al., CROI 2016
Results
• 78,000 individuals
• Baseline HIV prevalence 10%
– West Uganda 6%
– East Uganda 3%
– Kenya 20%
UNAIDS 90-90-90 Target Exceeded
Cascade coverage among prevalent adult stable HIV+
100%
UNAIDS
Target
90%
80%
70%
60%
50%
96% 97%
40%
30%
91% 94%
80%
86% 89% 90%
70%
20%
10%
0%
% HIV+ w/ Prior Dx
Baseline
% Prior Dx ever on ART
Follow Up Year 1
% Ever on ART w/ Supp
Follow Up Year 2
Year 2: >80% HIV+ Virally Suppressed
Cascade coverage among prevalent adult stable HIV+
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
UNAIDS
Target
82%
77%
48%
% all HIV+ w/ Supp
Baseline
Follow Up Year 1
Follow Up Year 2
Conclusions
• Population viral suppression increased from
48% to 82% during two years of the SEARCH
intervention
• Baseline lower suppression in men and youth
– After two years of intervention, disparity among
men reduced
– Suppression remains below target in youth
• SEARCH Study poised to evaluate the impact of
achieving the UNAIDS target on HIV incidence,
health, education and economic outcomes.
– Primary Endpoint: Paris 2017
DRUGS
DRUGS: NEW DATA ON TRIPLE ART
ARIA: study design
Open-label randomised non-inferiority phase 3b study
Open-label,
randomized
1:1
DTG/ABC/3TC FDC
DTG/ABC/3TC FDC
Continuation phase
ATV/r +TDF/FTC FDC
Randomization
Week 48
primary analysis
•
Key eligibility criteria: women, ART-naive, HLA-B*5701 negative, HIV-1 RNA >500 c/mL,
hepatitis B negative
•
•
Stratification: by HIV-1 RNA (≤ or >100,000 copies/mL), CD4+ count (≤ or >350 cells/mm3)
•
Primary endpoint: proportion with HIV-1 RNA <50 c/mL at Week 48 using the FDA snapshot
algorithm (-12% non-inferiority margin)
Women who became pregnant were withdrawn and, if possible, offered entry into a
DTG/ABC/3TC pregnancy study
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
Global Enrollment
160
Number of subjects
140
N=499 randomized
134
120
100
80
60
40
66
54
50
44
40
28
20
0
25
20
16
11
9
2
Country
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
Demographics and
baseline characteristics
Age, median (range), y
Race, n (%)
African heritage
White
Asian
Hepatitis C, n (%)
CDC category, n (%)
Asymptomatic
AIDS
HIV-1 RNA (log c/mL)
>100,000 (c/mL), n (%)
CD4+ cell count
<350 (cells/mm3), n (%)
DTG/ABC/3TC
(n=248)
ATV/r +TDF/FTC
(n=247)
37.5 (19-79)
37.0 (20-65)
102 (41)
115 (46)
22 (9)
16 (6)
108 (44)
107 (43)
23 (9)
21 (9)
210 (85)
11 (4)
4.48
69 (28)
370
130 (52)
208 (84)
9 (4)
4.44
66 (27)
380
123 (50)
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
Snapshot outcomes at week 48:
ITT-E and PP populations
Virologic outcomes
Treatment differences (95% CI)
100
82
HIV-1 RNA <50 c/mL, %
DTG/ABC/3TC (ITT-E, n=248)
86
76
80
71
DTG/ABC/3TC
ATV/r+TDF/FTC (ITT-E, n=247)
DTG/ABC/3TC (PP, n=230)
3.1
ATV/r+TDF/FTC (PP, n=225)
60
ATV/r+TDF/FTC
10.5
17.8
ITT-E
(primary)
40
2.6
9.7
16.8
PP
20
14
6
11
6
12
15
13
8
0
Virologic
success
Virologic
non-response
No virologic
data
-12-10 -8 -6 -4 -2 0 2 4 6 8 10 12 14 16 18 20
• DTG/ABC/3TC is superior to
ATV/r+TDF/FTC with respect to
snapshot in the ITT-E (<50 c/mL) at
Week 48, P=0.005
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
Snapshot Outcomes at Week 48: ITT-E
Virologic response
Virologic non-response
Data in window not below threshold
Discontinued while VL not <50*
No virologic data
Discontinued study due to AE or death
Discontinued study for other reasons
Missing data during window but on study
DTG/ABC/3TC
(n=248)
ATV/r+TDF/FTC
(N=247)
203 (82%)
16 (6%)
4 (2%)
12 (5%)
29 (12%)
9 (4%)
15 (6%)
5 (2%)
176 (71%)
35 (14%)
16 (6%)
19 (8%)
36 (15%)
18 (7%)
14 (6%)
4 (2%)
Differences in response rates driven by Snapshot virologic non-response and lower
rates of both discontinuations due to AEs in the DTG/ABC/3TC group.
*Includes categories: Discontinued for lack of efficacy and Discontinued for other reason
while not below threshold
AE, adverse, event; ITT-E, intent-to-treat exposed
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
Treatment emergent resistance
•
The resistance analysis was performed on subjects meeting confirmed virologic
withdrawal (confirmed ≥400 c/mL on or after Week 24)
DTG/ABC/3TC
(n=6)
ATV/r +TDF/FTC
(n=4)
INSTI
0
0
NRTI
0*
1
0
1
0
0
Resistance Analysis
M184V
PI
*Two
subjects receiving DTG/ABC/3TC had either K219K/Q (TAM) or E138E/G at CVW
with no reduced susceptibility to DTG/ABC/3TC. K219K/Q is not selected for by ABC or
3TC nor does it affect their fold change
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
Most Frequent AEs and Relative Risk
Favors DTG/ABC/3TC
Favors ATV/r+TDF/FTC
Nasopharyngitis
Nausea
Upper respiratory tract infection
Headache
Dizziness
Vomiting
Urinary tract infection
Diarrhoea
Back pain
Rash
Fatigue
Abdominal pain
Cough
Dyspepsia
Hyperbilirubinemia
Jaundice
Ocular icterus
0
5
10
15
20
Most frequent AEs* (%)
DTG/ABC/3TC, n=248
25
0
.125
.25
.5
1
2
4
Relative risk with 95% CI
ATV/r+TDF/FTC , n=247
* Randomized Phase (up to Week 48); All AEs reported by >5% in at least one treatment group.
AE, adverse event; CI, confidence interval.
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
Psychiatric AEs
DTG/ABC/3TC
FDC
N=248
n (%)
ATV/r+
TDF/FTC FDC
N=247
n (%)
Any event
35 (14)
35 (14)
Insomnia
10 (4)
9 (4)
Anxiety
5 (2)
7(3)
Depression
5 (2)
7 (3)
Suicidal ideation
4 (2)
3 (1)
Depressed mood
3 (1)
4 (2)
Abnormal dreams
2 (<1)
Panic attack
DTG/ABC/3TC
FDC
N=248
n (%)
ATV/r+
TDF/FTC FDC
N=247
n (%)
Acute psychosis
0
1 (<1)
Affect lability
0
1 (<1)
Anxiety disorder
0
1 (<1)
Confusional state
0
1 (<1)
0
Hallucination, visual
0
1 (<1)
2 (<1)
2 (<1)
Intentional self-injury
0
1 (<1)
Agitation
1 (<1)
0
Bipolar disorder
1 (<1)
0
Irritability
0
1 (<1)
Elevated mood
1 (<1)
0
Mania
0
1 (<1)
Mood altered
1 (<1)
2 (<1)
Panic disorder
0
1 (<1)
Mood swings
1 (<1)
0
Nightmare
1 (<1)
2 (<1)
Stress
0
1 (<1)
Sleep disorder
1 (<1)
2 (<1)
Event
Event
Orrell C, Hagins D, Belonosova E, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract TUAC1012.
ARIA: conclusions
• Triumeq superior to Truvada + atazanavir/ritonavir
for first-line treatment in women
• This the 3rd study to show superiority over ATV/r:
– ACTG 5257: Truvada with RAL or DRV/r superior to ATV/r
– ACTG 5202: sub-analysis: EFV superior to ATV/r in women
• Is it time for BHIVA to ‘downgrade’ atazanavir??
DRUGS: NEW DOSING OF TRIPLE
ART
ONCEMRK
Cahn P, Kaplan R, Sax P et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract FRAB0103LB.
Baseline characteristics
Cahn P, Kaplan R, Sax P et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract FRAB0103LB.
Results
• Once daily 1200mg RAL non-inferior to 400mg twice
daily (88.9% vs 88.3% at week 48):
– OD: 5/14 had resistance testing, 4/5 RAL mutations
– BD: 3 had resistance tests, 2 no RAMS, 1 failed
• Numerically more serious AEs and AE
discontinuations in BID dosing arm
• Based on these findings, the European Medicines
Agency has accepted the OD formulation of
raltegravir for review, and Merck plans to request US
FDA approval later this year
Cahn P, Kaplan R, Sax P et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract FRAB0103LB.
What does this mean??
• Some UK clinics already use RAL OD
• RAL cheap – will it remain so????
DRUGS: TWO NOT THREE
PADDLE: Pilot of 1st line dual ART,
dolutegravir + 3TC
• Week 24 results at EACS 2015, Week 48 results at IAS
2016, planned continuation to week 96
– Patients had screening VL 5,000-100,000, all suppressed by
W8
– 18/20 maintained virologic suppression through Week 48
• 1 PDVF at Week 36 resuppressed on same ART by Week 60*
• 1 suicide deemed unrelated to study drugs between W24 and W36
– Well tolerated, all AEs reported in first week of therapy
• Phase III GEMINI study (planned n=700 patients) DTG
+ 3TC vs DTG + TDF/FTC
*baseline VL >100,000; 3 others with baseline VL >100,000 maintained suppression
Cahn P, Rolón MJ, Figueroa MI, et al. 21st International AIDS Conference; July 18-22, 2016; Durban, South Africa. Abstract FRAB0104LB.
LATTE-2 Study: Maintenance Therapy With
Injectable Cabotegravir and Rilpivirine
Induction period
Maintenance period
CAB 400 mg IM + RPV 600 mg IM
Q4W (n=115)
CAB loading dose at Day 1
CAB 600 mg IM + RPV 900 mg IM
Q8W (n=115)
CAB 30 mg +
ABC/3TC for
20 weeks
(N=309)
CAB loading doses at Day 1 and Week 4
CAB 30 mg + ABC/3TC PO QD (n=56)
Add RPV
4 weeks
Day 1
Randomization
2:2:1
Week 32
Primary analysis
Dosing regimen selection
Margolis D, et al. 23rd CROI; Boston, MA; February 22-25, 2016. Abst. 31LB.
Week 48
Analysis
Dosing regimen
confirmation
Week 96b
LATTE-2: Week 32 Primary Endpoint:
HIV-1 RNA <50 c/mL by Snapshot (ITT-ME)
HIV-1 RNA <50 c/mL, %
100
95*
94*
Oral
91
IM
Q8W
80
Q8W (n=115)
Q4W (n=115)
60
12.2
-4.8
oral CAB (n=56)
40
Q4W
20
4
<1
4
<1
5
5
0
Virologic
success
Virologic
non-response
No virologic data
-5.8
11.5
• No resistance detected in any study arm
• 82% experienced grade 1 injection site reactions, 17% grade 2 (moderate) – most
commonly pain, swelling, or nodules; one death (epilepsy), cause unclear
• Suppressive ART with IM cabotegravir and rilpivirine appears safe and effective; further
studies planned
Margolis D, et al. 23rd CROI; Boston, MA; February 22-25, 2016. Abst. 31LB.
LATTE-2 Study: Patient Outcomes
How satisfied are you with
your current treatment?
How satisfied would you be to continue with
your present form of treatment?
1%
100%
100%
3%
1%
1%
2%
3%
Patient Percent
80%
29%
80%
60%
60%
40%
40%
20%
20%
0%
97%
96%
71%
Q8W (n=106)
Q4W (n=100)
Oral CAB (n=49)
More
Neutral
Less
Margolis D, et al. 23rd CROI; Boston, MA; February 22-25, 2016. Abst. 31LB.
0%
29%
98%
98%
71%
Q8W (n=106)
Q4W (n=100)
Oral CAB (n=49)
More
Neutral
Less
SPECIFIC AIMS
• Qualitatively explore perspectives and experiences with
LAI ART among LATTE-2 trial participants and clinical
care providers
•
•
•
•
•
How do patients experience the injections?
How do patients experience coming to clinic?
How does LAI ART compare to daily oral?
Who are the “right” patients for LAI ART?
How and where to best deliver LAI ART?
METHODS
– Semi-structured in-depth interviews (n=39)
• Purposive sample of 27 trial participants receiving LAI ART & 12
clinical providers in the US & Spain
• All trial interview participants had completed at least 32 weeks
of LAI ART following 20 weeks of oral ART
– Thematic content analysis conducted
• Textual data coded for a priori and emergent domains
• Salient themes extracted for patients and providers
INJECTION EXPERIENCES
– Majority of participants reported some level of side effects
• Mostly soreness and minor bruising at site for 1-2 days
– Some managed these effects with
Ibuprofen/Acetaminophen
• Minority of participants reported more intense reactions
– Hardness at injection site, fever, impaired mobility issues
– Broad agreement that side effects were “worth it”
• “One day is nothing…it’s as if you have a day with a
headache. You take Ibuprofen and that’s it. You put up with
it. It’s temporary”. –Spain, Male trial participant
• “It might be painful, but it’s better than pills”. –US, Male trial
participant
DELIVERY: WHO, WHERE, HOW
– Who: Agreement on the need “skilled” or “trained”
professional to administer injections such as doctor or nurse
– Where: In context of ongoing clinical care (HIV or primary
care); some participants mentioned community centers
– How/how often: “Less is better”; many participants relayed
the hope for quarterly or less frequent injection schedules.
DTG + RPV for treatment-experience
patients
• DTG plus RPV OD offered to patients with long-term
suppression and prior failure on >1 previous regimen
• 38 patients enrolled to switch
– Patients receiving median of 4.3 pills
– 38% of patients switched due to drug–drug interactions
– 33% switched due to toxicity
Diaz A, Casado F, Dronda F, et al. 21st International AIDS Conference (AIDS 2016); July 18-22, 2016; Durban, South Africa. Abstract TUPDB0106.
Baseline characteristics
Diaz A, Casado F, Dronda F, et al. 21st International AIDS Conference (AIDS 2016); July 18-22, 2016; Durban, South Africa. Abstract TUPDB0106.
Baseline characteristics
• Most exposed to ≥ 3 drug classes before switch
– 55% had failed drugs from ≥ 3 drug classes
– 45% had major mutations to ≥ 2 drug classes
– No INSTI primary resistance mutations
Diaz A, Casado F, Dronda F, et al. 21st International AIDS Conference (AIDS 2016); July 18-22, 2016; Durban, South Africa. Abstract TUPDB0106.
Results
• Through Week 48, no virologic failures
– 100% (38/38) suppressed at Week 4, 92% (35/38) at Week 48
– Remaining 3 patients discontinued study by Week 48
• Gastrointestinal toxicity (n = 1)
• Drug–drug interaction with omeprazole (n = 1)
• Physician’s decision (n = 1)
• DTG/RPV exhibited improved safety profile at Week 48 vs
baseline, including improved liver function tests,
improved lipid profile, and stable kidney function
• Bilirubin and hepatic enzymes significantly lower at Week
48 vs baseline
Diaz A, Casado F, Dronda F, et al. 21st International AIDS Conference (AIDS 2016); July 18-22, 2016; Durban, South Africa. Abstract TUPDB0106.
Conclusions
• DTG/CAB + RPV looks promising for many lines of
therapy
• Lack of data in treatment-experienced requires
CAUTION
• Switching anyone to an untested/undertested
regimen requires clear rationale, discussion and
documentation of risks/benefits
FINAL POINTS
UNAIDS: 90-90-90-90?
90 90 90 90
%%
Diagnosed
Lazarus JV et al. BMC Med. 2016; 14: 94.
%
%
On treatment
%
Undetectable
%
Good healthrelated QoL
‘Good health-related quality of life’
• Two domains:
– Co-morbidities
– Self-perceived quality of life
• Co-morbidities particularly concentrated in:
– Those treated in the earliest ART era
– Those who have had more severe immunosuppression
Lazarus JV et al. BMC Med. 2016; 14: 94.
Charlize Theron
“The truth is, we have every tool we need to prevent
the spread of HIV. Every tool we need”
“Condoms. PrEP. PEP. ART. Awareness. Education”
“And yet, 2.1 million people, 150,000 of them children,
were infected with HIV last year”
“2030….there are four more International AIDS
Conferences between now and then. They must be our
last”
Diaz A, Casado F, Dronda F, et al. 21st International AIDS Conference (AIDS 2016); July 18-22, 2016; Durban, South Africa. Abstract TUPDB0106.
My goal
Laura
Waters
said….
Thank you!
?
[email protected]
@drlaurajwaters