HIV/AIDS remains a significant global health issue, despite advancements in treatment and prevention methods. At the forefront of these advancements is Dr. Michelle Cespedes, a distinguished Professor of Medicine and Director of HIV Service at Mount Sinai Hospital. In her presentation during the ID Week, Dr. Cespedes presented a comprehensive overview of HIV care, discussing new data that could shape the future direction of HIV care. This article aims to provide an in-depth analysis of her presentation, focusing on the key takeaways and their implications for HIV care.
Strategies to Reduce Mother to Child Transmission:
Dr. Cespedes began her presentation discussing strategies to reduce Mother to Child Transmission (MTCT) of HIV. She highlighted the increasing data supporting the safety of Tenofovir Alafenamide (TAF) based regimens for MTCT. The safety of these regimens is crucial as it provides a pathway to prevent the transmission of HIV from mother to child, thereby reducing the incidence of pediatric HIV . Additionally, she emphasized the importance of Shared Decision Making regarding breastfeeding and the need for increased monitoring during pregnancy, particularly for regimens with limited data. These insights are invaluable as they contribute to the ongoing efforts to curb MTCT of HIV.
Use of Long-Acting Cabotegravir (LA CAB) + Rilpivirine (RPV) in Challenging Populations:
The presentation also touched upon the use of LA CAB+RPV in challenging populations. These populations are typically characterized by adherence issues due to various factors such as social isolation, mental health disorders, and financial instability. Despite these challenges, Dr. Cespedes presented data from real-world implementation projects, including the JABS project in Perth, Australia, and the Ward 86 Clinic in San Francisco. These projects showed promising results, suggesting that LA CAB+RPV could be an effective treatment option for these challenging
populations..
Second-Line Treatment for Virologic Failure:
In cases where the first-line antiretroviral therapy (ART) fails, it becomes necessary to explore second-line treatment options. Dr. Cespedes discussed this topic in detail, emphasizing that the design of a new regimen should be guided by the patient’s ARV history and results from resistance testing . She also outlined various treatment options based on susceptibility to Protease Inhibitors (PI) and/or Dolutegravir (DTG) [[5]]. This discussion is critical as it provides a roadmap for clinicians to follow when dealing with cases of first-line ART failure.
Introduction of Lenacapavir:
One of the most significant highlights of the presentation was the introduction of Lenacapavir, a first-in-class selective HIV-1 capsid inhibitor [[5]]. This novel agent disrupts the HIV viral life cycle at several points, offering a new approach to HIV treatment. Dr. Cespedes discussed the results of the CAPELLA Phase 3 trial, which demonstrated a significant decrease in HIV viral load with the addition of Lenacapavir to failing regimens . This breakthrough in HIV treatment is significant as it introduces a new agent that can be used in highly treatment-experienced (HTE) individuals.
REPRIEVE Study and its Impact on Cardiovascular Disease:
The presentation concluded with a discussion on the REPRIEVE study, a randomized trial aimed at preventing vascular events in HIV patients . Cardiovascular disease is a major concern for people living with HIV, and the REPRIEVE study aimed to understand the impact of statins on preventing heart disease and other major vascular events in patients who are HIV positive but would not be considered high risk by traditional risk factors. The REPRIEVE study’s findings underscore the importance of statins in HIV patient care and management .
The study revealed that the use of Pitavastatin led to a 35% reduction in major cardiovascular events compared to placebo . This is a significant finding, considering the increased risk of cardiovascular disease among people living with HIV. This outcome suggests that statins could play a pivotal role in preventing heart disease and other major vascular events in HIV patients.
Moreover, Dr. Cespedes highlighted several common questions associated with the REPRIEVE study . These included queries about whether these results can be expected for all statins and the mechanism of Major Adverse Cardiac Events (MACE) reduction, whether it’s LDL lowering or modification of inflammation. She also addressed queries on whether statins had any effects on other co-morbidities seen in HIV, and if there were changes seen in CV plaque in the substudy over time. These questions hint at the complexities involved in managing HIV and its associated risks, and the need for continued research and study.
In her summary, Dr. Cespedes reflected on the evolution of MTCT efforts, the efficacy of LA CAB+RPV in populations with traditional risk factors for adherence, and the consistent safety and efficacy of 2nd line treatment strategies that include either DTG or boosted DRV. She also mentioned the significant decline in viral load observed in patients with multidrug-resistant HIV-1 infection thanks to Lenacapavir, which is now approved for HTE . Lastly, she pointed out how immune activation, inflammation, and traditional CV risk factors contribute to excess risk – a risk only partially reversed by ART. However, the use of Pitavastatin lowers risk in PWH at low-moderate risk of cardiovascular disease .
Dr. Michelle Cespedes’ presentation at the ID Week offered a comprehensive overview of the state of HIV care and the direction it’s heading. From strategies to reduce MTCT and the use of LA CAB+RPV in challenging populations, to the introduction of novel treatment agents like Lenacapavir and the implications of the REPRIEVE study, Dr. Cespedes highlighted the ongoing advancements in HIV care.
As we continue to grapple with the global HIV/AIDS epidemic, these insights and developments offer hope for improved quality of care and better treatment outcomes for individuals living with HIV. The medical community awaits further research and data to continue improving these strategies and treatments, aiming for a future where HIV can be managed effectively, improving the quality of life for those affected.
In the larger context, these advancements underscore the importance of ongoing research and innovation in the field of HIV care. As we gain a better understanding of the virus and its impact on the human body, it becomes increasingly clear that a multi-faceted approach, incorporating prevention, treatment, and management strategies, is necessary to combat this global health issue. The work of Dr. Cespedes and her peers signifies a promising future in the fight against HIV/AIDS.
