The HIV Treatment Landscape

Segment Description: Joseph Eron, MD; Paul Sax, MD; W. David Hardy, MD; Eric S. Daar, MD; and Ian Frank, MD provide an overview of the current HIV landscape, with a discussion on the impact demographics, location, and sexual orientation have on prevalence and rate of infection.

Joseph Eron, MD: Hello, and thank you for joining this Contagion® Peer Exchange® titled “HIV Screening, Prevention, and Treatment Advances.” The treatment of HIV has a long history. There are currently over 40 individual and combination drugs approved for the treatment of HIV, and the life expectancy of a person with HIV nears that of a person not living with HIV. Challenges still remain regarding therapy, including tolerability, long-term adverse effects, and drug-drug interactions.

In this Contagion® Peer Exchange® panel discussion, I am joined by infectious disease specialists who are experts in managing HIV infection. We will review HIV treatment guideline updates and discuss important considerations that will help differentiate the current therapies. Emerging agents and novel management approaches will also be discussed.

I am Joseph Eron, a professor of medicine at the University of North Carolina School of Medicine in Chapel Hill.

Participating today on our panel are:

Dr. W. David Hardy. He’s an adjunct professor of medicine at Johns Hopkins University in Baltimore, Maryland.

Dr. Paul Sax. He’s the clinical director of the Division of Infectious Disease at the Brigham & Women’s Hospital in Boston, Massachusetts, and a professor of medicine at the Harvard Medical School.

Dr. Ian Frank, a professor of medicine at the University of Pennsylvania Perelman School of Medicine in Philadelphia, Pennsylvania.

And Dr. Eric S. Daar, the interim chair of the Department of Medicine and chief of the Division of HIV Medicine at Harbor-UCLA Medical Center and a professor of medicine at the David Geffen School of Medicine at UCLA in Los Angeles, California.

Thank you so much for joining us. Let’s begin.

So we’re going to start talking about screening and prevention. So Eric, give us a little sense of where we are in terms of infections in the United States—incidence and prevalence and where are we now?

Eric S. Daar, MD: Yeah. So the recent estimates are that there’s about 1.2 million people living with HIV in the United States, and I think more importantly, people have been carefully tracking incident of infections, challenging as it is to do, and this is where there has actually been some progress. And some of the progress may be linked to what we’re going to talk about during the course of this discussion when we talk about treatment and prevention, but after really decades of estimated 50,000 new infections per year, we now believe that it’s closer to around 40 or maybe even less than 40,000 per year. And there may be a lot of factors that are driving that, but it continues to be a really important metric to follow for our progress in trying to curb the epidemic in the United States. I think the other big challenge is recognizing where these infections are coming from and what are the things driving the epidemic?

Joseph Eron, MD: Because if you look by group, it’s not everybody kind of going down. There’s a difference by risk group.

Paul Sax, MD: Yeah. Predominantly it has been infections involving men who have sex with men in the United States as the leading risk category. And for that group, especially in the 20 to 30 age group, it’s actually increasing a little bit. And everywhere else it’s decreasing. So the second-largest category is heterosexual transmission among women, men to women, and in that group it’s declining. And aside from a few very well-recognized outbreaks, among injection drug users, the new infections are very rare.

W. David Hardy, MD: You can break that down even further. Among the MSM [men who have sex with men], it’s not even all MSMs; it’s primarily black and Hispanic MSMs, because transmission among white MSMs has actually come down pretty well.

Joseph Eron, MD: So, Ian, so what about different areas of the country in terms of new infections?

Ian Frank, MD: So there are major regional differences. The CDC divides the country into 4 different groups. They’re Northeast. Infection rates are actually going down. They’re also going down in the Midwest. The Southeast, which is actually the largest group, that includes all of the territory basically south of Pennsylvania down to Florida, and west to Texas. The rates of new infections there are stable, although in some areas they’re actually increasing a little bit. And in the far West, the infection rates are stable.

I want to though point out, because we often emphasize infections among young individuals, about 15% to 20% of new diagnoses are made in individuals ages 55 and above. And I just want to remind people of that fact because we need to remember to continue to test people if they’re at-risk or if they come in certainly with any indicator disease that could be associated with HIV. I want us to not overlook that.

Paul Sax, MD: I want to mention 1 other thing about testing, which is that there’s progress, when you look at the incidence of HIV in the United States, and this progress that Eric alluded to, it starts to improve back in around 2006, 2007 when the testing laws started getting more relaxed.

Joseph Eron, MD: Relaxed, sure.

Paul Sax, MD: So right now the proportion of people unaware that they have HIV infection in the United States is only about 12% to 15%. Whereas in 2004, 2005, it was about 30%. So we made a lot of progress in getting the people who were undiagnosed diagnosed.

W. David Hardy, MD: We also made it easier to get diagnosed with this rapid test that requires saliva and no longer blood drawing, which has actually helped a lot as well.

Eric S. Daar, MD: And I think we have to remember before we abandon our concerns about injection drug users, there is an opioid epidemic and there is reason to be concerned that we may see an uptake in the number of new infections.

Paul Sax, MD: We’ve had an outbreak in the Boston area over the past year in that it’s just been quite surprising to see a new HIV diagnosis in a young person who uses injection drugs. It’s the first time we’ve seen that in over a decade so it’s really.

Eric S. Daar, MD: We’ve had some very high-profile outbreaks over the last 5 years or so.

Ian Frank, MD: And needle sharing is happening because young people who are injecting are getting hepatitis C infections.

Joseph Eron, MD: Yeah, they definitely get hepatitis C.

Ian Frank, MD: So we know that that’s happening, but virologic suppression rates are surprisingly high among injection drug users. That’s probably the reason why infection rates are low. But I think the hepatitis C data is a warning sign, because it really means that if a few cases get introduced there’s the potential for rapid spread among intravenous drug users is relatively high.

Paul Sax, MD: Right. The half-life of some of the opiates of choice now, fentanyl in particular is so short, that in certain situations people who inject drugs are injecting 5, 10, 20 times a day. And so in that context there’s really a chance for explosive spread of HIV.

Joseph Eron, MD: Yeah. And I think also that, at least in North Carolina, and I don’t know about, the 2 epidemics just haven’t overlapped yet. So it’s poor, White, and rural for injection drug use in hepatitis C, and it’s poor Black and some a little bit also in the cities, and it just hasn’t intersected yet. So I don’t, I’m not sure that, that suppression in our injection drug users is the answer in North Carolina, but it might be.