Current Management of Human Immunodeficiency Virus (HIV)

According to the Centers for Disease Control and Prevention (CDC), more than 1.1 million Americans are infected with the human immunodeficiency (HIV) virus and roughly 14% of them are unaware of their infection. Since the start of the epidemic, there have been more than 700,000 deaths in the United States due to the progression of HIV to acquired immunodeficiency syndrome (AIDS). Currently, there are two types of the HIV virus worldwide, with HIV-1 being the most prevalent.

Management of HIV is intricate and requires rapid initiation of antiretroviral therapy (ART) at the time of diagnosis. Due to the nature of the virus mutating quickly, complex multi-drug regimens are required for effective viral suppression. The primary goals of treatment include controlling viral replication, preventing resistance, decreasing medication side effects and pill burden, minimizing long-term co-morbidities and preventing new infections. In order to achieve these goals, adherence must be at least 95% to the patients’ prescribed ART. Early treatment must involve patient engagement to reveal any barriers influencing the patient’s ability to adhere to the ART and approaches should be tailored to an individual’s needs.

Current Therapies for HIV and Looking Ahead

HIV medications are grouped into seven drug classes according to their mechanism of action. These drug classes include non-nucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs), protease inhibitors (PIs), fusion inhibitors, CCR5 antagonists, integrase strand transfer inhibitors (INSTIs), and post-attachment inhibitors. An individual’s first HIV regimen usually includes a 3-drug regimen consisting of two NRTI’s plus an INSTI or an NNRTI or a PI boosted with cobicistat. It is very common for patients to switch from one regimen (or combination of drugs) to another due to intolerance or development of resistance. Therefore, patient education and coordinated multidisciplinary care are paramount to successful and effective ART therapy.

The ART pipeline remains robust with the development of new co-formulations to address issues with adherence and side effects along with biologics to treat specific populations with multidrug resistant HIV. Since the fourth quarter of 2017, several new drugs received FDA-approval to target safety and efficacy along with validating two-drug regimens as a durable maintenance treatment.

The table below illustrates the most recent FDA drug approvals and provides a preview of agents currently under investigation in the pipeline.

Additionally, HIV vaccines and passive immunity models are currently under investigation with a goal of curing HIV. To date, there is no vaccination proven to be fully effective against preventing the spread of HIV. In 2009, a landmark trial known as “RV144” in Thailand provided the first signal of HIV vaccine efficacy. Several current phase II clinical trials used findings from this study to supplement research. More recently, passive immunization models involving injections or IV infusions with broad neutralizing antibodies (bNAbs) appear promising. While developing an HIV vaccination is challenging due to characteristic rapid mutations, significant progress is underway.

2018 Quarter Two WellInformed Table Contents