Advancements in Patient Care for HIV and AIDS
The medical community has made tremendous strides in testing, treatment, and quality of life for patients living with HIV/AIDSsince the firstwas observed on Dec. 1, 1988.
MarshallGlesby, MD, PhDisassociatechief of the Division of Infectious Diseases anddirector of the Cornell HIV Clinical Trials Unit at the ֱ Medical College.HereDr.Glesbydiscusses the progress thatmedicalresearchersatֱand beyondhavemade in HIV/AIDS research.
What have been some of the innovations in testing for HIV/AIDS in recent years?
Now there aretests that can both detect antibodies to HIV and HIV antigen (parts of the virus itself). This newer test facilitates the diagnosis of very recently acquired HIV infection before the body has produced antibodies that are detected in a traditional HIV test.
This has shortened the“window”period where someone may have recently acquired HIV infection,but notyethave a positive HIV test. Diagnosing HIV in the acute stage--when people sometimes have flu-like symptoms--is particularly important,becausetherapid initiation of HIV treatment at this stage may be theoretically beneficial and help reduce the likelihood of transmission.
People with HIV/AIDS are.What has made this possible?
People are living longer with HIV as a result of more effective HIV therapy. In fact, modeling studies suggest that people who start HIV medications before their immune systems have been weakened by the virus,andwho don’t smoke,are expected to have lifespans comparable to people who do not have HIV.
The drug combinations that we use now are generally very well tolerated and simple to take for most individuals living with HIV. Many people are able to take one pill once a day, a drastic improvement from the gold standard combination therapies used in the mid-1990s,whichoften consisted of up to 20 pills a day.
The Centers for Disease Control(CDC)released aabout the reduction of HIV-related death rates. Would you please comment on that?
The CDC attributes the reduction in death rates among people with HIV from 2010to2018 primarily to more people becoming aware of their HIV status and increasing viral suppression rates. Simpler, better tolerated antiretroviral regimens has undoubtedly contributed to improved outcomes.
Unfortunately,disparities remain. Mortality rates due to HIV are higher among Blacks, persons of multiple races, women, and transgender women. There is still work to be doneinimprovingrates of early HIV diagnosis in these communities,more rapidly linkingand retainingpatients tocare after diagnosis,andinitiating HIV therapy in a timely fashion.
Please explainwhat it means if the virus isundetectableor“untransmittable.”
In the last few years, the concept of undetectableanduntransmittable,or U,has become widely accepted. Data indicate that people who adhere to their HIV medications and have HIV viral loads (levels of HIV in the bloodstream) that are “ܲԻٱٲ”--meaningthe viral load isbelow the level of detection by a standard lab testand theycannot transmitthevirus sexually to other people. It can be very liberating for someone living with HIV to learn this.
There has been news recently about an injectable drug that may be more effective in preventingHIV than some once-a-day oral medications. Would you please discuss that?
Earlier this year, results became available from an important NIH-funded clinical trial of pre-exposure prophylaxis (PrEP) that investigators from WeillCornellMedicineparticipated in,called HIV Prevention Trials Network (HPTN) 083. This trial compared an injectable, investigational drugcalledCabotegravir, to the FDA-approved combination pill of tenofovir/emtricitabine in cisgender men and transgender women who have sex with men. The study found that rates of acquiring HIV infection were reduced bytwo thirdsin those randomly assigned to the injectable drug.
We know from other studies that many people who are at risk of HIV infection would prefer an injection everyeightweeks to taking a daily pill forPrEP. Recently, data from a similarly designed trial called HPTN 083 in cisgender women in sub-Saharan Africa demonstrated that injectable cabotegravir was superior to the oral tenofovir/emtricitabine combination.
Whatother HIV/AIDSclinical trials are happening at ֱMedicine?
Broadly speaking, we are conducting trials in several different areas. One is in simplifying HIV therapy, includinga trial of injectable HIV drugs for people who have had difficulty taking antiretroviral pills consistently and whose HIV has not been well controlled; andtrials of infusions of monoclonal antibodies against HIV to see if they can keep HIV under control after the participant stops takingantiretroviral pills.
We’re also researching the complications of HIV and co-infections, such assimplified, shorter course treatment of acute hepatitis C virus infection in people with or without HIV, andstrategies aimed at preventing anal cancer in people with HIV.
Another active area of investigation at WCM is HIV and aging.As the population of people living with HIV gets older, we are seeing a higher frequency of aging-related complications, such as frailty, compared to people without HIV.
Our researchers also are looking intoHIV cure strategies, includingstem cell transplantation with umbilical cord-derived cells that are resistant to HIV infection for people who have a medical condition, such as leukemia or lymphoma,whichrequires a transplant.Our investigators also aretesting interventions aimed at reducing the size of the HIV reservoir, which is a group of immune cells in the body that are infected with HIV, but are not actively producing new HIV.
How, if at all, has the context of the pandemic affected HIV/AIDS patients, and overall research in the field?
Even prior to the COVID-19 pandemic, many people living with HIV have faced challenges from social isolation, stigma, depression, and substance use. The pandemic has likely exacerbated these challenges for some.
It is not clear whether people living with HIV are at higher risk of becoming sick with COVID-19,or if they have worse outcomes. Our experience at NYPH-WCM suggests that outcomes of patients hospitalized with COVID-19 do not differ based on HIV status. Other studies have yielded conflicting findings.
COVID-19 has had a major impact on all areas of research,including HIV. Our dedicated research staff conducted countless study visits by telephone or telemedicine during the peak of the pandemic in NewYorkCity. Study participants who needed injections were able to come for their visits, which were conducted in the safest ways possible.
Colleagues who conduct laboratory-based research in HIV initially faced closure of their labs and, upon re-opening, reduced capacity due to the need for social distancing. Nonetheless, the work continues. Just as findings from HIV research has had an impact on other areas of medicine, COVID-19 research will likely provide insights into virology and immunology that will affect HIV and other medical conditions.