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Consultant Physician, HIV/GU Medicine
Mortimer Market Centre
CNWL NHS Trust
London, United Kingdom
Laura Waters, FRCP, MD, has disclosed that she has received consulting fees from Cipla, Gilead Sciences, Janssen, MSD, Mylan, and ViiV Healthcare.
The 23rd International AIDS Conference was a key event on the HIV clinician’s calendar, providing a platform for the latest research, science, and policy on the treatment and prevention of HIV infection. AIDS 2020: Virtual highlighted emerging data on new ARV therapies, adverse events (AEs) associated with treatment, and novel investigational ART strategies.
AIDS 2020: Virtual was held entirely online, providing exciting opportunities for clinicians to engage with the latest data and 24-hour access to on-demand content. To aid clinicians in navigating the latest data and guidance on HIV treatment options, I worked with Clinical Care Options and my colleagues Linda-Gail Bekker, MBChB, DTM&H, DCH, FCP(SA), PhD; Pedro Cahn, MD, PhD; and Monica Gandhi, MD, MPH, to develop a multipart CME/CPE-certified satellite symposium: “What’s Hot in HIV Treatment”, which is now available on demand. This symposium featured 2 components: 1) Concise updates on the latest data in HIV treatment; and 2) A discussion, recorded live on July 7, 2020 providing insights into how we navigate the current treatment landscape and where we anticipate new treatment options will fit in. Both sessions focused on key areas of HIV management: optimal use of newer ARV agents and strategies, individualizing ART for women of childbearing potential and during pregnancy, the impact of evolving data on AEs during ART, and the anticipated roles of emerging and investigational novel ART strategies. I highlight below some of the clinical challenges and controversies that we face in contemporary practice, many of which were discussed during the symposium.
Navigating Current ART Options
Choice of first-line ART depends on tolerability, drug interactions, patient preference and likely adherence, resistance profile, and, for women, pregnancy intentions and contraception. With INSTI-based regimens dominating preferred options for ART initiation, is there a role for boosted PIs? Poorly adherent patients or those who have difficulties engaging in care remain an important group where PIs can be useful. Although resistance to INSTIs is uncommon, it does develop, and boosted PIs are crucial for that setting.
Data are emerging on the potential metabolic effects of tenofovir alafenamide (TAF). For patients at high risk of metabolic-related comorbidities, is a 2-drug regimen a preferred option in place of a TAF-based triple regimen? Where does the doravirine/lamivudine/tenofovir disoproxil fumarate fixed-dose combination fit into current treatment strategies? These are just a few of the challenges that we discussed.
Optimizing ART in Women
There is often a considerable delay between licensing new ARVs and accumulating adequate data on their safety in pregnant women. This is challenging because the drugs for which we have the most evidence during pregnancy are those that are no longer preferred for the general population in many consensus guidelines. We end up relying on data from retrospective and prospective cohorts and registries, which as we have seen with dolutegravir, may lead to difficult choices regarding preferred therapies. We saw additional data on ART safety in pregnancy at AIDS 2020: Virtual. How will these new findings influence ART selection in women of childbearing potential?
Individualizing ART Based on Evolving Safety and Tolerability Data
Weight gain associated with INSTIs and TAF has emerged as a major topic of interest among clinicians and patients. Are weight gain and other metabolic changes associated with potential clinical harm? How should we interpret evidence from some studies of AEs in people receiving INSTIs, particularly neuropsychiatric AEs seen with dolutegravir?
Update on ART Strategies Under Investigation
The development of long-acting injectable ARVs, such as cabotegravir/rilpivirine and islatravir, is a huge leap forward and something that is very attractive to patients. Implementation of new treatment paradigms will present challenges because patients will have to come to clinic at least every 2 months. What role will long-acting injectables play in HIV care, and what kind of infrastructure will be required to facilitate their use?
Get up to speed on the latest preconference data by watching short, prerecorded foundational presentations by our faculty or view the recorded live discussions on how these data will influence clinical practice. In addition, download slides from the symposium, featuring all the key data from the symposium.