Use of long-acting injectable antiretroviral agents for human immunodeficiency Virus: A review

Human immunodeficiency virus infection challenges: Current therapeutic limitations and strategies for improved management through long-acting injectable formulation

HIV infection has been a severe global health burden, with millions living with the virus and continuing new infections each year. Antiretroviral therapy can effectively suppress HIV replication but requires strict lifelong adherence to daily oral medication regimens, which presents a significant challenge. Long-acting formulations of antiretroviral drugs administered infrequently have emerged as a promising strategy to improve treatment outcomes and adherence to HIV therapy and prevention. Long-acting injectable (LAI) formulations are designed to gradually release drugs over extended periods of weeks or months following a single injection. Critical advantages of LAIs over conventional oral dosage forms include less frequent dosing requirements, enhanced patient privacy, reduced stigma associated with daily pill regimens, and optimised pharmacokinetic/pharmacodynamic profiles. Several LAI antiretroviral products have recently gained regulatory approval, such as the integrase strand transfer inhibitor cabotegravir for HIV preexposure prophylaxis and the Cabotegravir/Rilpivirine combination for HIV treatment. A leading approach for developing long-acting antiretroviral depots involves encapsulating drug compounds in polymeric microspheres composed of biocompatible, biodegradable materials like poly (lactic-co-glycolic acid). These injectable depot formulations enable high drug loading with customisable extended-release kinetics controlled by the polymeric matrix. Compared to daily oral therapies, LAI antiretroviral formulations leveraging biodegradable polymeric microspheres offer notable benefits, including prolonged therapeutic effects, reduced dosing frequency for improved adherence, and the potential to kerb the initial HIV transmission event. The present manuscript aims to review the pathogenesis of the virus and its progression and propose therapeutic targets and long-acting drug delivery strategies that hold substantial promise for enhancing outcomes in HIV treatment and prevention.

HIV/AIDS in Indonesia: current treatment landscape, future therapeutic horizons, and herbal approaches

HIV/AIDS is still a major worldwide health concern, and Indonesia is making efforts to mitigate its effects. Antiretroviral therapy (ARV), which aims to decrease viral replication, boost immunological function, and lengthen the lifespans of persons living with HIV/AIDS, is the cornerstone of Indonesia's strategy. The availability of ARV has significantly increased, yet problems including stigma and the requirement for regular medication adherence still exist. To address the broader needs of those affected by HIV/AIDS, Indonesia lays a major focus on comprehensive care, which includes mental health and social support, in addition to ARV. Data show that, despite progress, there is still a stigma surrounding HIV/AIDS, which affects patient outcomes and access to care. With vigorous research into cutting-edge antiretroviral medications and treatment techniques, Indonesia has a thriving future therapeutic landscape. The goals of these programs are to increase treatment effectiveness, decrease side effects, and increase access to cutting-edge treatments. Preventive methods, such as PrEP (pre-exposure prophylaxis), are making progress, and efforts to find a cure are gaining prominence. Notably, HIV/AIDS management plan of Indonesia heavily relies on natural remedies. Patient care incorporates traditional Indonesian medicine, such as jamu and several herbal medicines. Although there is little scientific proof to support the effectiveness of these herbal remedies, complementary and alternative therapies frequently employ them to manage symptoms and promote general wellness. In terms of the 95-95-95 targets, Indonesia is making an effort to comply with these international goals by seeking to diagnose 95% of HIV-positive individuals, provide sustained ARV to 95% of those diagnosed, and achieve viral suppression in 95% of ARV recipients. Although there are gaps in reaching these aims, progress is being made, in part because of the aforementioned challenges. In summary, Indonesia employs a multimodal approach to HIV/AIDS management, including traditional herbal cures, continuous research into cutting-edge treatments, and conventional ARV. In order to enhance overall health outcomes and create a healthier society, the future of HIV/AIDS treatment in Indonesia is concentrated on expanding therapeutic alternatives, reaching the 95-95-95 targets, decreasing stigma, and improving access to care.

Micro and nanotechnologies: The little formulations that could

The first publication of micro- and nanotechnology in medicine was in 1798 with the use of the Cowpox virus by Edward Jenner as an attenuated vaccine against Smallpox. Since then, there has been an explosion of micro- and nanotechnologies for medical applications. The breadth of these micro- and nanotechnologies is discussed in this piece, presenting the date of their first report and their latest progression (e.g., clinical trials, FDA approval). This includes successes such as the recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines from Pfizer, Moderna, and Janssen (Johnson & Johnson) as well as the most popular nanoparticle therapy, liposomal Doxil. However, the enormity of the success of these platforms has not been without challenges. For example, we discuss why the production of Doxil was halted for several years, and the bankruptcy of BIND therapeutics, which relied on a nanoparticle drug carrier. Overall, the field of micro- and nanotechnology has advanced beyond these challenges and continues advancing new and novel platforms that have transformed therapies, vaccines, and imaging. In this review, a wide range of biomedical micro- and nanotechnology is discussed to serve as a primer to the field and provide an accessible summary of clinically relevant micro- and nanotechnology platforms.

Approved Nanomedicine against Diseases

Nanomedicine is a branch of medicine using nanotechnology to prevent and treat diseases. Nanotechnology represents one of the most effective approaches in elevating a drug‘s treatment efficacy and reducing toxicity by improving drug solubility, altering biodistribution, and controlling the release. The development of nanotechnology and materials has brought a profound revolution to medicine, significantly affecting the treatment of various major diseases such as cancer, injection, and cardiovascular diseases. Nanomedicine has experienced explosive growth in the past few years. Although the clinical transition of nanomedicine is not very satisfactory, traditional drugs still occupy a dominant position in formulation development, but increasingly active drugs have adopted nanoscale forms to limit side effects and improve efficacy. The review summarized the approved nanomedicine, its indications, and the properties of commonly used nanocarriers and nanotechnology.

Realizing the promise of long-acting antiretroviral treatment strategies for individuals with HIV and adherence challenges: an illustrative case series

BACKGROUND

Adherence to antiretroviral treatment (ART) remains the cornerstone of optimal HIV outcomes, including viral suppression (VS), immune recovery, and decreased transmission risk. For many people with HIV (PWH), particularly those with early-acquired HIV, structural, behavioral, and cognitive barriers to adherence and competing priorities related to life events may be difficult to overcome, resulting in nonadherence. Long-acting injectable antiretroviral therapies (LAI-ART) may be a useful strategy to overcome some of these barriers. However, to date, the approved LAI-ART strategies (e.g., cabotegravir and rilpivirine (CAB/RPV)) have targeted those who have already attained viral suppression, precluding their use in the 40% of adolescents and young adults (AYA) that VS has eluded.

CASE PRESENTATION

Ms. X is a 30-year-old woman with perinatally-acquired HIV and barriers to adherence. Despite many interventions, she remained persistently viremic, with resultant immune suppression and multiple comorbid opportunistic conditions, and viral load (VL) > 10,000,000 copies/ml. Given her longstanding history of poor adherence to an oral regimen, a switch to monthly intramuscular (IM) injections and biweekly infusions of ibalizumab were initiated leading to decreased viral load to 8,110 copies/ml within two weeks. Ms. H is a 33-year-old woman with cognitive limitations due to childhood lead poisoning. Her viral load trajectory took a downward turn, precipitated by various life events, remaining elevated despite intensive case management. Initiation of LAI-ART (CAB/RPV) in this patient led to an undetectable VL (< 20 copies/ml) within two months of treatment initiation. Miss Y. is a 37-year-old woman with perinatally-acquired HIV and chronic challenges with nonadherence and longstanding immunosuppression with CD4 < 200 cells/mm³ for > 5 years. She received a 1-month oral lead-in (OLI) of cabotegravir/rilpivirine, followed by the injectable loading dose. She has since adhered to all her monthly dosing appointments, sustained VS, and transitioned to a bi-monthly injection schedule.

CONCLUSION

These three individuals with HIV (perinatally and non-perinatally acquired) with longstanding nonadherence and persistent viremia were successfully initiated on LAI-ART through the process of care coordination and the collective efforts of the care team, highlighting the barriers, challenges, and the multidisciplinary coordination needed to assure successful implementation of this strategy for the most vulnerable of patients.