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IDWeek 2103: The Past, Present, and Future of HIV Treatment

More that 25 years after approval of the first antiretroviral drug -- AZT in 1987 -- several presenters at the 2nd IDWeek meeting last week in San Franciscodiscussed the history, state-of-the-art, and future of HIV treatment. Modern antiretroviral therapy (ART) has kep countless people alive, but researchers and people with HIV are now looking toward biomedical prevention and ultimately a cure.

The history actually came towards the end, with Myron Cohen from the University of North Carolina at Chapel Hill -- who has worked in the field since the earliest years of the epidemic -- giving the plenary Joseph Smadel lecture on Saturday, entitled "The Evolution of Antiretroviral Agents: From Survival to Prevention to Cure."

Cohen is perhaps best known as the principal investigator for HPTN 052, a large trial in Africa which showed that HIV transmission was reduced by 96% when the HIV positive partner in a discordant heterosexual couple started immediate antiretroviral treatment regardless of CD4 T-cell count. Hearing these results after working on the study for 20 years, he recalled, "was like winning Dancing with the Stars."

While prevention may be icing on the cake, the most compelling reason for starting ART early would be that it improves the health of people with HIV. HTPN 052 showed that this was the case for people with mid-range CD4 counts. A randomized clinical trial looking at when to start treatment for people with high CD4 counts -- like the ongoing START Study -- will require thousands of participants and take years. But in the meantime, Cohen said, U.S. guidelines recommending ART for everyone diagnosed with HIV are "almost certainly right."

In his talk on HIV, aging, and inflammation, Steven Deeks from UCSF offered evidence that early treatment may help ameliorate the excessive immune activation and inflammation that contribute to non-AIDS conditions such as cardiovascular disease and cancer, which are occurring at earlier ages among HIV positive people.

Now that the virus itself can be controlled, the field of HIV medicine is shifting towards management of chronic age-related conditions -- especially in places like San Francisco, where more than half of people with HIV are age 50 or older.

"I give people ART -- that's easy to do -- and then I'm no longer an HIV doc," Deeks said. While there's probably "no magic bullet" for preventing age-related complications, healthy diet and exercise are key. "We can't wait until [HIV positive people] are old and frail to do something about it," he added. "The goal is not surviving as long as possible, it's staying healthy."

Looking to the Future

Looking toward the future of HIV care, Michael Saag from the University of Alabama gave an overview of the Affordable Care Act and what it means for people with HIV.

On the upside, many more people are expected to get coverage, either through expanded Medicaid or through new insurance exchanges. On the downside, some of the states with the most low-income people with HIV are the same ones that have refused to expand their Medicaid programs. "Most states that claim to be for 'states' rights' and autonomy have opted for the federal plan by refusing to set up state exchanges," he observed.

Asked by HIV Medicine Association board chair Michael Horberg whether he predict that things will progress in the southeast, Saag said he that thinks over the next 2-3 years there will be a "domino effect" and the federal government will be "willing to work with states to find a way forward."

Ideally, Saag said, shifting more direct medical care to Medicaid would allow Ryan White Care Act funds to be used for public health efforts such as expanded HIV testing and linkage to and retention in care. He proposed that medical clinics could partner with community-based organizations to offer services like case management and substance abuse treatment that Medicaid does not cover.

Saag stressed the importance of HIV doctors signing up as health plan primary care providers so patients will have a choice of HIV-knowledgeable clinicians (see the HIVMA website for more info). "Obamacare is not the answer, it's just a start, but it is a step on the road to something better," he concluded.

While apologizing for being "one-sided" and acknowledging that some of his HIV colleagues disagree about the ACA, he stressed, "Whether we like it or not, we need to know the law and participate on behalf of our patients."

All fields of medicine must control costs, and generic drugs may be part of the solution. Veteran HIV clinician John Bartlett from Johns Hopkins discussed the forthcoming advent of generic antiretrovirals as widely used medications like efavirenz (Sustiva) go off patent.

Bartlett expressed some skepticism about the ACA -- calling it "socialized medicine run by capitalists" -- as well as the U.S. guidelines calling for immediate ART for all. He noted that medications account for around 70% of the annual cost of HIV care, which generic drugs could reduce substantially.

In particular, the availability of generics will offer the option of using combinations of cheaper drugs instead of brand-name coformulations. "If you ask a patient whether he wants to take 1 pill or 3, he'll prefer 1," Bartlett said, "but what if you tell him taking 3 will save $6,000 and you'll give him half?"

Saag commented that this is a short-term issue, and within 5 to 10 years enough antiretrovirals will have gone off patent that generic manufacturers will also be able to make coformulations and single-tablet regimens. Moderator Rachel Walensy, an expert in ART cost issues, noted that in fact some of these are already produced and available in poor countries.

Prevention and a Cure

While improvements in HIV treatment have saved millions of lives and improved the quality of many more, prevention and a cure remain the ultimate goals.

Connie Celum from the University of Washington in Seattle, an investigator with large trials showing the efficacy of Truvada pre-exposure prophylaxis, presented an overview of the current state of biomedical prevention, one of the fastest-moving areas in the HIV field. In addition to his aging lecture, Deeks also gave an overview of HIV cure research (similar to a talk he gave he gave at a community forum in San Francisco earlier in the week).

"Treating your way out of an epidemic is almost possible," Cohen said in his Saturday lecture. "[Treatment as prevention] is important, but not a replacement for a vaccine or a cure."

"The race to cure HIV is incredible right now -- I'm sure this is like the race to find a polio vaccine," he continued. "Even if investigators don't cure AIDS, I'm quite sure they'll change the approach to therapy forever."

"We're at the bridging point of pandemic," he concluded. "There was no light at the end of tunnel in 1985, but now it's a totally different world. Now is not the time to talk about cutting back research funds, its time to redouble our investment."

10/11/13