January 18, 2016
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
Something interesting happens when you poll people who treat HIV -- and people who have HIV -- about whether they'd prefer a treatment option that consists of a periodic injection or infusion in place of the pill or pills that they take every day.
Lots of them say yes. Even people who are taking just one pill a day, and are having no side effects.
As a famous comedian (repeatedly) says, What's the deal with that?
Given the success of currently available oral therapies -- in which essentially 100% of people who take it are virologically suppressed -- why do so many people say they want shots instead?
Part of it, of course, is the way the question is framed, and human nature. There's a tendency to favor the shiney new toy. Here's a typical headline on this topic:
And the simple question -- "Would you prefer a shot over pills?" -- implies an optimal available strategy. Let's imagine a single shot administered quarterly, with a small required volume, low rates of injection site reactions, few side effects, and plenty of forgiveness around missed doses. Now we're talking!
The reason I bring this up is because a couple of recent studies show that non-pill treatments for HIV are at the very least feasible.
Most promisingly, there's the LATTE-2 study of the long-acting antivirals cabotegravir and rilpivirine -- given as injections either every 4 or every 8 weeks -- which maintained virologic suppression as well as a standard 3 drug regimen. (More details expected soon.)
And there's this study of the broadly neutralizing antibody VRC01, which when infused to patients with viremia, dropped HIV RNA 1.1-1.8 log (10-100 fold) in 6 of 8 with a single infusion. It follows an earlier study showing an even more potent antiviral response using a different antibody, 3BNC117. Both treatments dropped HIV RNA long after the single dose.
So we're on our way, right? Soon we'll be offering injections or infusions as an alternative to pills, and we'll all live happily ever after!
But it's not so simple. Here are a few compelling reasons why we're not going to see these injectables as viable treatment options in the near future:
Granted, even as the cabotegravir/rilpivirine treatment is currently configured -- a few shots every 8 weeks -- there will be a subset of patients for whom this is their preferred way of receiving therapy. Could be cost-effective, too, especially if it's priced reasonably.
But I'm thinking it's going to be small group who actually prefer this treatment to a single pill a day. And we're not going to see it anytime soon.
Pop Tarts, Jerry?
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