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Unmet Needs in HIV Management and Treatment Landscape Trajectory


In their final thoughts, Eugene McCray, M.D., and Steven Peskin, M.D., MBA, FACP, share insights into unmet needs surrounding HIV treatment management.

Steven Peskin, M.D., MBA, FACP: It’s almost universally true that any condition has unmet needs. In the area of HIV [human immunodeficiency virus], we’d like to have a vaccine. The National Institutes of Health has been driving this, trying to work on this both at the National Institute of Allergy and Infectious Diseases and through extramural grants to academic institutions. That would certainly be an unmet need. Another unmet need, as we’ve talked about before, would be the notion of better coordination of care, management of complications of HIV, sometimes of the disease itself, sometimes of the medications. Again, we’re not perfect with respect to the frequency of viral load testing, perhaps early warning signals of a reemergence of infection. These would be unmet needs. I would say, thinking a bit futuristically, whether someone might have some type of nanotechnology, something that’s circulating and innocuous, that gives a signal to the patient or their clinical team, something like that, to give an even earlier sign that therapy is starting to falter. But again, I’d say at the top of my list for unmet needs would be a vaccine.

Eugene McCray, M.D.: I think the biggest unmet need is the development of therapies that allow convenient dosing schedules, that do not necessitate strict adherence to meal-related timing restrictions, and remain active in the face of resistant mutation. I think that’s paramount because this is true, especially for patients who have a lot of treatment experience in whom HIV has developed resistance to two or more drugs. There are very few new drugs out there for those individuals, and the big concern we have is that resistance will be developing for those very soon. That’s one thing, even though there have been a lot of achievements in terms of drugs being made available, a lot of those achievements have been in therapies for naive patients or patients who don’t have multiple drug resistance.

I think the other thing is recognizing there are other cofactors that can lead to patients developing multiple drug resistance and addressing some of those cofactors. Things like, as I mentioned earlier, addressing this situation of homelessness, substance abuse, and other drug use. These are unmet needs that can really affect the treatment and outcome for people with drug-resistant HIV.

How is the treatment of HIV changing in the future? There is a lot of interesting stuff that’s happening. First, there are the long-acting injectables that we talked about earlier, the six-month and 12-month regimens. That’s very exciting, and I anticipate that within the next year or so we’re going to have approval of one or more long-acting injectable, six-month or 12-month regimens. The other thing that isn’t talked about much is long-lasting implants. These are 12-month implants that slowly deliver one or more potent antiretroviral drugs, much like those that are used for contraception. And these implants are being looked at for HIV prevention, or PrEP, pre-exposure prophylaxis, and for HIV treatment. Some of those clinical trials are ongoing, and I think those are very promising and will be another tool in our toolbox to treat and prevent acquired MDR [multidrug resistant HIV].

But for me, the most exciting thing is developing an effective HIV vaccine utilizing the mRNA [messenger ribonucleic acid] technology that was used for the COVID-19 vaccines. HIV vaccine development has really gotten a boost and has accelerated a lot in the year 2022 with candidate vaccines that are utilizing this mRNA technology. There are at least three or more products out there, and some of them are showing very promising results. So, I think a vaccine using mRNA technology is probably the thing I’m most excited about. And for the first time in many years, it looks promising.

Steven Peskin, M.D., MBA, FACP: As we look to the next three to five years with the treatment of HIV, certainly for persons with HIV, we need to continue to reinforce health literacy. We’ve seen examples in the HIV community, notably in the male gay community, a keen awareness of the condition and in a sense support. But in other groups, not so much. With persons who have contracted HIV through heterosexual activity, you tend to see less of that deep insight. The use of self-monitoring is important, persons in the comfort of their own apartment, home, or flat doing self-monitoring and then being able to bring that information forward to trained clinicians, to appropriately act upon that.

We’ve talked a bit about the use of telehealth. I think in most chronic conditions, telehealth represents an important opportunity to extend the care team. We talk about the importance of a care team, and that is part of the here and now, but it’s also part of the future of health care. Where each individual, whether they be a medical assistant or a physician is operating at the top of the license. I see that in all areas, but HIV certainly as well, as part of the future. Then again, part of the future in the next three to five years is the continued development of new therapies, novel therapies that are addressing multidrug resistant HIV. And as has been done with some of the oral medications that have several drugs in one pill, making it easier for the patient to treat themselves with highly active antiretroviral therapy.

HIV is one disease that is most certainly visible and important to health plans. From the early days, I remember when AZT [azidothymidine] was first introduced. It sounds like ancient history. I was working at a health plan in Boston, Massachusetts, and there was this great concern that we laugh about now, that AZT was going to be the end of health insurance plans because they were all going to be bankrupt because of this therapy, which of course is ludicrous. But we can look back on that now, and it has become a disease that fortunately is a chronic condition. I would say the health plan and the payer community working in concert with the clinical systems, ecosystems, and their geography are committed to improving and continuing to improve what has already been a great triumph for U.S. and world medicine, to arrest this from being a death sentence within one to two years to being a chronic medical condition.

Transcript edited for clarity.

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