Efficacy, pharmacokinetics and neurocognitive performance of dual, NRTI-sparing antiretroviral therapy in acute HIV-infection

Public health implications of diagnosing and treating acute HIV

PURPOSE OF REVIEW

The earliest months of HIV infection are characterized by high viral loads and elevated transmissibility, particularly during the acute (preseroconversion) phase. Transmission prevention during early HIV requires diagnostic tools that narrow the window between viral acquisition and reactive test, followed by rapid linkage to effective antiretroviral therapy (ART). Here, we review recent advances related to diagnosing and treating persons during early HIV, with a particular focus on acute HIV infection (AHI).

RECENT FINDINGS

Point-of-care (POC) fourth-generation antigen/antibody tests have mixed performance, often dependent on the pretest probability of early infection within the screened population. Risk score algorithms demonstrate the potential for prioritizing resource-intensive tests, such as POC HIV RNA, to those most likely to have AHI, but their predictive performance varies across populations, complicating implementation. Emerging and re-emerging infections, including SARS-CoV-2 and mpox, present opportunities for and challenges to symptom-driven AHI screening. Daily oral ART with standard first-line regimens quickly suppresses viremia during AHI, but long-acting injectable drugs are yet to be explored for this indication.

SUMMARY

Few practice-changing results related to diagnosing or treating persons with early HIV have been released in the last 18 months. Accurate POC HIV RNA tests could leapfrog fourth-generation POC assays, but they remain unavailable for routine use. Implementation science approaches are needed to guide use of evidence-based strategies for early HIV screening, and additional research on same-day ART linkage, including injectable ART, could produce dramatic impacts on forward transmission during this period.

Rapid viral suppression using integrase inhibitors during acute HIV-1 infection

BACKGROUND

Antiretroviral therapy (ART) is recommended for all individuals with HIV infection, including those with acute HIV-1 infection (AHI). While recommendations are similar to those for chronic infection, efficacy data regarding treatment of acute HIV is limited.

METHODS

This was a single arm, 96-week study of a once-daily integrase inhibitor (INSTI)-based regimen using elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (EVG/COBI/FTC/TDF) in AHI. Primary endpoint was proportion of participants with HIV-1 RNA <200 copies/mL and <50 copies/mL by treatment weeks 24 and 48, respectively. We also examined time to viral suppression and weight gain after treatment initiation. Outcomes and characteristics were compared with a historical AHI cohort using a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen with efavirenz/emtricitabine/tenofovir disoproxil fumarate (EFV/FTC/TDF).

RESULTS

Thirty-three participants with AHI were enrolled with 31 available for analyses. Most were African American (61%) and men who have sex with men (73%). Median age was 26 (IQR 22-42). Demographics were similar between the two AHI cohorts. By Week 24, 100% in the INSTI and 99% in the NNRTI cohort were <200 copies/mL; by Week 48, 100% in both cohorts were <50 copies/mL. Time to viral suppression was shorter in the INSTI cohort (median 54 versus 99 days). Mean weight change was similar with a 3.6 kg increase in the INSTI cohort and 2.4 kg in the NNRTI cohort at 96 weeks.

CONCLUSIONS

INSTI-based ART during AHI resulted in rapid and sustained viral suppression. Over 96 weeks, weight increased in the INSTI-based cohort but was similar to weight increase in a historical NNRTI-based AHI cohort.

The contemporary immunoassays for HIV diagnosis: a concise overview

Recent advances in human immunodeficiency virus (HIV) diagnostics have improved the management of disease progression significantly, which have also boosted the efficacy of antiviral therapies. The detection of HIV at the earliest is very important. A highly recognized and effective virological biomarker for acute HIV infections is p24 antigen. This brief overview is based on advances of HIV diagnosis while focusing on the latest HIV testing technologies including HIV-specific antigens detecting assays of both anti-HIV antibodies and p24 antigen. In addition to other emerging molecular diagnostics for acute HIV infection, the utilization of p24 antigen has been summarized. Moreover, it has been explained how these immunoassays have reduced the window period for detection of HIV in the acute stage of infection.

Pharmacology of HIV Cure: Site of Action

Despite significant advances in HIV treatment over the past 30 years, critical barriers to an HIV cure persist. The HIV reservoir, defined at both the cellular and anatomical level, constitutes the main barrier to cure. While the mechanisms underlying the reservoir are not yet well understood, one theory to explain persistence at the anatomical level is that subtherapeutic exposure to antiretroviral therapy (ART) within certain tissue compartments permits ongoing replication. Characterizing ART pharmacology throughout the body is important in the context of these potential pharmacologic sanctuaries and for maximizing the probability of success with forthcoming cure strategies that rely on latency reversal and require ART to prevent reseeding the reservoir. In this review, we provide a comprehensive overview of ART and latency reversal agent distribution at the site of action for HIV cure (i.e., anatomical sites commonly associated with HIV persistence, such as lymphoid organs and the central nervous system). We also discuss methodologic approaches that provide insight into HIV cure pharmacology, including experimental design and advances within the computational, pharmaceutical, and analytical chemistry fields. The information discussed in this review will assist in streamlining the development of investigational cure strategies by providing a roadmap to ensure therapeutic exposure within the site of action for HIV cure.

Risks and benefits of reducing the number of drugs to treat HIV-1 infection

Introduction: Despite the efficacy and safety of antiretroviral therapy, new treatment options are needed to address the concerns of patients and physicians regarding long-term toxicities, costs, and convenience of lifelong antiretroviral therapy. To achieve this goal, one strategy is to reduce the number of drugs in the antiretroviral regimen.Areas covered: We review the recent evidence on the efficacy and safety of reduced drug regimens and their potential risks and benefits. There is currently strong evidence showing that some two-drug regimens have a comparable efficacy and short-term safety compared to standard three-drug regimens. The fixed-dose combination of dolutegravir/lamivudine is already an alternative for many treatment-naïve and virologically suppressed HIV-1 infected adults supported by large randomized clinical trials. The co-formulation dolutegravir plus rilpivirine is also a switch strategy for maintenance therapy. Long-acting injectable cabotegravir plus rilpivirine has already regulatory approval, and islatravir plus doravirine is an expected option in the near future. Some two-drug regimens have not been as successful.Expert opinion: Long-term safety issues of these two-drug regimens remain to be determined, but with the overwhelming evidence available in virological control and short-term safety, the potential benefits of some of these two-drug regimens appear to outweigh the risks.