Highlighting the Value of Patient-Focused Care in HIV

Timothy J. Wilkin, MD, MPH, a professor of medicine at Weill Cornell Medical College, outlined developments and treatment options for individuals with HIV in his talk at this year’s National Association of Managed Care Physicians Spring Managed Care Forum, held in Orlando, Florida, April 21-22.

To combat the HIV epidemic, providers and researchers have the goal of reducing new HIV infections by 90% in 10 years, an effort that will include increased focus on diagnosis, treatment, prevention, and response to outbreaks, Wilkin explained.

Currently, half of all new HIV infections take place in just 48 counties throughout the United States, while rural transmission and outbreaks are focused in 7 states. From a public health standpoint, Wilkin hopes to create a routine approach to HIV testing by offering it to everyone.

Although no curative therapies for the disease exist, available medications can lower viral loads to undetectable levels, and additional medications like pre-exposure prophylaxis (PrEP) prevent spread of the disease to those who have yet to be exposed to the virus.

A key mission in the goal of reducing HIV is promoting care engagement so individuals can start medication early and maintain optimal adherence rates. But barriers to this effort include factors like substance use, mental health conditions, poverty, stigma, and medicinal adverse events.

“HIV really disproportionately affects different populations,” Wilkin said. “It really affects people of color. It impacts people with lower socioeconomic means, people that have less ability to access care.” In the United States, data show the epidemic is most prevalent among young Black men who have sex with men.

The optimal time to initiate viral-reducing medication is immediately post diagnosis, Wilkin explained. Research has found that people given antiretroviral therapy (ART) right away were not only more likely to start ART but also more likely to be retained in care.

“There was something about receiving HIV medications right away that I suppose really underscored the importance of the medication and really drew people into their own care for HIV and that had lasting effects,” he said. “The goal is to get people on medication as soon as possible.”

This finding is critical because it reduces the amount of time individuals have to transmit HIV to others. But this outcome is also more likely when the medication is easy to take, Wilkin stressed.

Both oral daily medication and monthly injections are available for HIV treatments, and the format of administration can oftentimes be left up to the patient. Some patients, Wilkin noted, are uncomfortable taking a daily oral pill for HIV and would rather only receive monthly injections.

Although treatments like integrase-inhibitor based regimens exist for this patient population that are very tolerable, effective, and drive down viral loads quickly, some other medicines may induce treatment resistance in patients.

Understanding individual patient characteristics that increase the risk of treatment resistance and adverse drug effects is crucial and will ultimately improve clinical and economic outcomes.

For heavily treatment experienced patients, who constitute a small minority of those with HIV, “it can be difficult to construct effective HIV regimens,” Wilkin said.

To better target therapies for this group, providers need to sort through patient history to sum up resistance seen since they were first infected with HIV. One method of carrying this out is genotypic testing. But for very complex patients, phenotypic testing may be warranted.

For HIV, phenotypic testing allows providers “to see which drugs and what amounts of the drugs are predicted to work for the patient.”

One available drug for treatment-resistant patients is fostemsavir, which functions to block HIV from entering the cells. In a clinical trial, researchers found that over 2 weeks the drug led to significantly greater reduction in HIV viral load, and over time, 60% of individuals were able to become undetectable.

Lenacapavir is also being studied in either weekly oral doses or subcutaneous injections every 6 months. It has yet to be approved but is being researched for both HIV treatment and prevention.

Long-acting cabotegravir and rilpivirine is currently available in clinical practice as an antiviral therapy, but does have an accompanying resistance issue and can only be prescribed as a switch treatment. “This is probably what gives me as a clinician a little pause,” said Wilkin.

This effect was also more common in individuals with HIV subtype A6/A1, which is less common in the United States, and who had a body mass index of at least 30 kg/m² at baseline.

With regard to mortality, HIV is not the main cause of death in patients with uncontrolled levels of the virus, as most individuals die from complications including cancer and heart disease. These individuals tend to not receive a diagnosis early on or not adhere to medication.

“There are also places in the country where access to medication is difficult. And so, in some places, those barriers are also places where the stigma about HIV is much greater and you know, [there are] people just really not engaging in care or getting diagnosed,” Wilkin said.

Globally, some countries have superior rates of diagnosis and suppression compared with the United States, pointing to the growth in access to medication worldwide.

However, sustaining these programs over years may pose challenges, because “unfortunately, people aren’t cured,” Wilkin concluded. “You just keep stacking up millions and millions of people on these medications. Continuing to treat larger and larger numbers is a challenge.”