The following is a video and transcript excerpt from an interview conducted with David Alain Wohl, M.D., discussing highlights and clinical takeaway messages from the 2021 Conference on Retroviruses and Opportunistic Infections (CROI 2021), which took place in March. In this video, Wohl talks through new findings on HIV prevention, especially those that aim to expand and transform the options available to people for pre-exposure prophylaxis (PrEP).
As far as prevention for HIV, it has been somewhat of an uneventful time over the last few years. Certainly, we have TDF/FTC [emtricitabine/tenofovir disoproxil fumarate, Truvada], which has been the workhorse. And I think, looking at the longer view, what started out sort of stumbling had really reached the crescendo where more and more people were aware of it. The company that manufactures it did invest in a marketing campaign that got a lot of attention, TV ads, et cetera. And I think that was great.
We’ve seen, I think, almost as far as we can go with TDF/FTC uptake, et cetera. There’s just some limits: People don’t want to take a pill a day. And while TAF/FTC [emtricitabine/tenofovir alafenamide, Descovy] offers some convenience, perhaps, and for us providers not to worry as much about some of the things we worry about where [the potential adverse effects of] TDF—I think in the PrEP space, it didn’t really make too much of a difference. Certainly, the DISCOVER trial has provided us with some great data about the differences between TAF and TDF. But both of them work really well.
So, where do we go from here? I think there’s a few different ways.
At this conference, what’s notable is: The folks in Paris have done a great job showing us that a non-daily schedule for taking PrEP continues to work really well. And that, whether or not people choose to take it every day or take it on this more intermittent schedule, it seems to work really well. That’s very pragmatic.
We saw, from HPTN 083, really great data that shows that cabotegravir [CAB, Vocabria], an injectable, works really well—in fact, better than oral therapy with TDF/FTC, largely probably because of adherence. People just take the shots every two months as opposed to taking a pill every day. They just do it better. I think that’s a harbinger of what’s to come. I’m looking very much forward to being able to offer that to people.
But even beyond that, I think what we saw at CROI this year is that people are thinking really hard about other options, whether that be islatravir, which is a really special antiretroviral that has a lot of flexibility in how it can be administered. We heard data about possibly implants that could provide yearly prophylaxis—a whole year of prophylaxis with an implant—and maybe monthly oral therapy with that same compound.
We heard about lenacapavir, a long-acting antiviral that could be very, very useful, and that the company is very interested in and aggressively pursuing for prevention.
So, I’m really excited. I think that we’re going to see a revolution, a renaissance in PrEP over the next couple of years that will give a lot more choice to people.
You know, again: I think current PrEP has done what it can do. I’m disheartened by just how many people stop their PrEP because they just don’t want to take a pill, even just a few times a week. So, this is really hopeful for me, and I think something to keep your eye out on.
We’ll see CAB first. That’ll be great for some people. And then we’re going to start to see all sorts of modalities that make it easier to protect yourself against HIV. And then I really do think we’re going to see incredible declines in HIV below—you know, we used to be 50,000 [new infections in the U.S.] a year. Now, it’s 40,000 a year, maybe less. And we don’t know what the pandemic has done to things, but I’m anticipating we’re going to see even fewer infections per year as we get better HIV therapy and better prevention.
I think that [vaginal rings containing dapivirine] can be helpful, especially for women. Now, women don’t make up the huge amount of HIV infections here in the United States, but they do elsewhere. So, I think that’s going to be really key.
Here in the United States, I think we just have to figure out more: Where are the women who are getting infected? How do we intervene to protect those women? Because I think there are some geographic hotspots where many of those women live. And I think there’s opportunities there to concentrate some efforts in a very supportive and helpful way.
But globally, rings can be increasingly important as a woman-controlled intervention along with these other things, and not requiring the same kind of prescriptions, or the same kind of going to a clinic and getting an injection, that some of these other modalities [will]. They’ve been a long time coming.
It’s about time we start to see some of these things come to the clinic and come to the bedside table, because a lot of these have just been conceptual for so long and slow in development.