The medical community has made tremendous strides in testing, treatment, and quality of life for patients living with HIV/AIDS since the first World AIDS Day was observed on Dec. 1, 1988.
Marshall Glesby, MD, PhD is associate chief of the Division of Infectious Diseases and director of the Cornell HIV Clinical Trials Unit at the Weill Cornell Medical College. Here Dr. Glesby discusses the progress that medical researchers at Weill Cornell Medicine and beyond have made in HIV/AIDS research.
Now there are tests that can both detect antibodies to HIV and HIV antigen (parts of the virus itself). This newer test facilitates the diagnosis of very recently acquired HIV infection before the body has produced antibodies that are detected in a traditional HIV test.
This has shortened the “window” period where someone may have recently acquired HIV infection, but not yet have a positive HIV test. Diagnosing HIV in the acute stage--when people sometimes have flu-like symptoms--is particularly important, because the rapid initiation of HIV treatment at this stage may be theoretically beneficial and help reduce the likelihood of transmission.
People are living longer with HIV as a result of more effective HIV therapy. In fact, modeling studies suggest that people who start HIV medications before their immune systems have been weakened by the virus, and who don’t smoke, are expected to have lifespans comparable to people who do not have HIV.
The drug combinations that we use now are generally very well tolerated and simple to take for most individuals living with HIV. Many people are able to take one pill once a day, a drastic improvement from the gold standard combination therapies used in the mid-1990s, which often consisted of up to 20 pills a day.
The CDC attributes the reduction in death rates among people with HIV from 2010 to 2018 primarily to more people becoming aware of their HIV status and increasing viral suppression rates. Simpler, better tolerated antiretroviral regimens has undoubtedly contributed to improved outcomes.
Unfortunately, disparities remain. Mortality rates due to HIV are higher among Blacks, persons of multiple races, women, and transgender women. There is still work to be done in improving rates of early HIV diagnosis in these communities, more rapidly linking and retaining patients to care after diagnosis, and initiating HIV therapy in a timely fashion.
In the last few years, the concept of undetectable and untransmittable, or U, has become widely accepted. Data indicate that people who adhere to their HIV medications and have HIV viral loads (levels of HIV in the bloodstream) that are “undetectable”--meaning the viral load is below the level of detection by a standard lab test and they cannot transmit the virus sexually to other people. It can be very liberating for someone living with HIV to learn this.
There has been news recently about an injectable drug that may be more effective in preventing HIV than some once-a-day oral medications. Would you please discuss that?
Earlier this year, results became available from an important NIH-funded clinical trial of pre-exposure prophylaxis (PrEP) that investigators from Weill Cornell Medicine participated in, called HIV Prevention Trials Network (HPTN) 083. This trial compared an injectable, investigational drug called Cabotegravir, to the FDA-approved combination pill of tenofovir/emtricitabine in cisgender men and transgender women who have sex with men. The study found that rates of acquiring HIV infection were reduced by two thirds in those randomly assigned to the injectable drug.
We know from other studies that many people who are at risk of HIV infection would prefer an injection every eight weeks to taking a daily pill for PrEP. Recently, data from a similarly designed trial called HPTN 083 in cisgender women in sub-Saharan Africa demonstrated that injectable cabotegravir was superior to the oral tenofovir/emtricitabine combination.
Broadly speaking, we are conducting trials in several different areas. One is in simplifying HIV therapy, including a trial of injectable HIV drugs for people who have had difficulty taking antiretroviral pills consistently and whose HIV has not been well controlled; and trials of infusions of monoclonal antibodies against HIV to see if they can keep HIV under control after the participant stops taking antiretroviral pills.
We’re also researching the complications of HIV and co-infections, such as simplified, shorter course treatment of acute hepatitis C virus infection in people with or without HIV, and strategies aimed at preventing anal cancer in people with HIV.
Another active area of investigation at WCM is HIV and aging. As the population of people living with HIV gets older, we are seeing a higher frequency of aging-related complications, such as frailty, compared to people without HIV.
Our researchers also are looking into HIV cure strategies, including stem cell transplantation with umbilical cord-derived cells that are resistant to HIV infection for people who have a medical condition, such as leukemia or lymphoma, which requires a transplant. Our investigators also are testing interventions aimed at reducing the size of the HIV reservoir, which is a group of immune cells in the body that are infected with HIV, but are not actively producing new HIV.
Even prior to the COVID-19 pandemic, many people living with HIV have faced challenges from social isolation, stigma, depression, and substance use. The pandemic has likely exacerbated these challenges for some.
It is not clear whether people living with HIV are at higher risk of becoming sick with COVID-19, or if they have worse outcomes. Our experience at NYPH-WCM suggests that outcomes of patients hospitalized with COVID-19 do not differ based on HIV status. Other studies have yielded conflicting findings.
COVID-19 has had a major impact on all areas of research, including HIV. Our dedicated research staff conducted countless study visits by telephone or telemedicine during the peak of the pandemic in New York City. Study participants who needed injections were able to come for their visits, which were conducted in the safest ways possible.
Colleagues who conduct laboratory-based research in HIV initially faced closure of their labs and, upon re-opening, reduced capacity due to the need for social distancing. Nonetheless, the work continues. Just as findings from HIV research has had an impact on other areas of medicine, COVID-19 research will likely provide insights into virology and immunology that will affect HIV and other medical conditions.