Treatment for people living with HIV (antiretroviral
therapy) is lifesaving and revolutionary as it has made HIV
akin to any other chronic disease. It has been proven that
those who are on treatment and remain virally suppressed,
live healthy and normal lifespans – comparable to those
without the virus – and there is zero risk of any further
HIV transmission from them.
But oral HIV
treatment has to be taken daily without fail. This could be
challenging given the fact that HIV treatment is
lifelong.
Recently, long-acting injectable
treatment options have been proven to be as effective as the
daily oral therapy. However, a very small number of those on
long-acting options reported virological failure (and higher
risk of HIV virus developing resistance against HIV
medicine, also referred to as drug-resistance or
antimicrobial resistance/AMR).
But is the long-acting
therapy for everyone?
A lot of such questions were
answered by Dr Jurgen Kurt Rockstroh, Head of Infectious
Diseases, Department of Medicine, University Hospital Bonn
in Germany. Dr Jurgen has earlier served as the Chairperson
of German AIDS Society, and President of European AIDS
Clinical Society (EACS) too. He gave a plenary talk at the
16th National Conference of AIDS Society of India (ASICON
2025) in Ahmedabad, India. Dr Jurgen was conferred upon the
ASI Lifetime Achievement Award by the Chief Minister of
Gujarat Bhupendra Patel and Dr Ishwar Gilada, Emeritus
President, ASI and Governing Council member of International
AIDS Society (IAS).
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Antiretroviral therapy is
lifesaving, revolutionised HIV care
Dr Jurgen said
that over 95% of people who are diagnosed positive for HIV
and initiated on first-line oral antiretroviral therapy soon
achieve viral suppression with undetectable viral load.
“An overwhelming body of clinical evidence has firmly
established that undetectable HIV viral load means that HIV
is untransmittable from these people, which is often
referred to as undetectable equals untransmittable or U
equals U/ U=U).”
Dr Jurgen added that “near to
normal life expectancy for people living with HIV is a
reality now if antiretroviral therapy is started early
enough and the person stays virally suppressed.”
He
pointed out that in the rare event of HIV virological
failure, there is a risk for drug-resistance development.
Less than 2% people who are on antiretroviral therapy
discontinue due to adverse events.
If all is good,
then why do we need new options?
Yes, HIV treatment
– daily oral regimen – is lifesaving and good – access
to which is critically important in a rights-based manner
for all those with HIV. However, there could be people who
might find it difficult to take daily pills or those who
want more choices of long-acting options.
Those people
with HIV who are unable to adhere to daily oral therapy or
face HIV-related stigma and risk of discrimination (for
example, 40% of people in a multi-country study said that
they fear that their HIV medicines would be found by others
and lead to HIV disclosure, stigma and discrimination), or
those who are struggling with treatment fatigue of a
lifelong therapy or wish for treatment simplification, or
those who do not want to be reminded of having HIV every day
– day after day (35% of study participants in a
multi-country study said this was a concern for them), or
those who have difficulties in swallowing pills, are the
ones who may consider long-acting treatment
options.
Dr Jurgen shared an example of a person who
opted for long-acting regimens: a woman living with HIV who
is a native of one of the African nations and under his
medical care in Germany, has a HIV negative child. She did
not want to disclose or risk disclosing her HIV status to
her child as she lives in a community-setting where HIV
disclosure could mean being forced out of the group. So, it
was important for her to ensure that others may not find her
medicines. That is why, she opted for long-acting therapy
and continues to remain virally suppressed and
healthy.
A study published in 2018 gauged interest in
potential new ARV therapies back then among 263 people with
HIV from clinics in Duke and University of South Carolina.
Four-fifths of these study participants came from racial and
ethnic minorities, 89% were virally suppressed and, on an
average, they were on antiretroviral therapy for around
twelve years.
In the study, two-thirds of the
respondents (61%) said yes to the choice of “taking a single
pill once a week,” followed by one-thirds of those (34%) who
opted for 2 injectables given in a clinic setting every two
months. Lowest interest was towards 2 plastic implants in
the forearm every six months as a mode of administering the
therapy.
Choice matters
Dr Jurgen Rockstroh
said that “Increased flexibility of delivery of
antiretroviral therapy is needed to meet the diverse needs
of people living with HIV. People continue to face physical,
emotional, and psychological challenges with daily oral
therapy. These challenges have been associated with poor
health outcomes, including low treatment satisfaction,
self-reported virological failure, suboptimal self-rated
overall health, and poor adherence.”
What is
long-acting HIV treatment?
Studies have shown that
long-acting injectable HIV treatment regimens of
cabotegravir and rilpivirine (intramuscular injection once
every month or every two months) are as effective as daily
oral regimens. Those people who may find it difficult to
adhere to a daily oral therapy or confront HIV disclosure or
stigma, may opt for long-acting ones if found eligible.
Long-acting regimens are recommended as a preferred option
for those people with HIV who are virologically suppressed
or those who are on a stable antiretroviral regimen and
might be facing challenges with daily oral
therapy.
Long-acting regimens are now recommended by
several HIV treatment guidelines, including those of US
Department of Health and Human Services, EACS, and
International Antiviral Society USA, among
others.
There are new options of administering
long-acting antiretroviral medicines, two of which
are:
– Intramuscular injections of
cabotegravir and rilpivirine medicines once
every two months
– Sub-cutaneous injections of
lenacapavir once every six months
Dr
Jurgen pointed out that taking intramuscular injections
could be a bit challenging as it could be painful and not
easy for everyone. Comparatively, subcutaneous injections
could be a little easier in this respect.
He said that
when supported by intensive follow-up and case management
services, injectable cabotegravir and rilpivirine may be
considered for people who otherwise meet the criteria – such
as, unable to take oral therapy, high risk of HIV disease
progression with CD4 below 200 or history of AIDS defining
complications, and the virus which is susceptible to both
cabotegravir and rilpivirine medicines.
Long-acting
injectable antiretroviral therapy options expand the number
of choices for those who may be struggling to overcome
HIV-related stigma or struggle with HIV disclosure but
“there is an existent risk of virological failure even in
fully adherent individuals, and virological failure is
associated with higher risk of drug-resistance development,”
said Dr Jurgen.
As more scientific evidence and
lessons from the roll-out of long-acting options come forth,
we need to ensure that every person living with HIV is able
to access the latest regimens of lifesaving antiretroviral
therapy – and all choices of treatment delivery options are
available and accessible to those who are eligible for
them.
Bobby Ramakant – CNS (Citizen News
Service)
(Bobby Ramakant is a World Health
Organization (WHO) Director General WNTD Awardee 2008 and
Health and Science Editor at CNS (Citizen News Service). He
also serves on the executive boards of Global Antimicrobial
Resistance Media Alliance (GAMA) and Asia Pacific Media
Alliance for Health and Development (APCAT Media). Follow
him on Twitter/X: @BobbyRamakant)
– Shared under
Creative Commons
(CC)
