Emerging Treatment Options for HIV

Joseph Eron, MD: We have some emerging treatment options. The 1 that’s probably the closest to market is called fostemsavir. It is before the FDA right now. We can’t predict what will happen, but they have to make a decision by the middle of August. Fostemsavir, like ibalizumab, blocks entry, but instead of binding to the cell, it binds to the virus, so it’s an attachment inhibitor. One advantage over ibalizumab is that it’s a pill, not an infusion. We have evidence that it has antiviral activity and does work in combination with other drugs. I think it will have a place in the world, but it’s 2 times a day. It’s likely for those people who have very limited treatment options.

It is available through compassionate use, though I’ve not used it in that setting. Have you used it in this setting?

Allison Agwu, MD, ScM: We have. I just saw a perinatal young woman who was out of options on a combination of fostemsavir, and ibalizumab with a nuke that is probably having a little bit of activity.

Joseph Eron, MD: That is the type of situation where we might be using these drugs. There is excitement because there are other drugs in the pipeline. In particular, there are long-acting agents in the pipeline. Allison, do you want to initiate this conversation and discuss the treatment and prevention?

Allison Agwu, MD, ScM: Yes, I think for all of us who have been treating HIV for years, we’ve all muttered the words, “We just need a shot,” or we just need something. And it’s exciting to hear that we are at the point where we’re considering shots that are injectables on the market and also long-acting oral agents. The closest to the combination of cabotegravir is an injectable integrase inhibitor and rilpivirine, which is a non—nucleoside reverse transcriptase inhibitor injectable. [They are used] together for treatment, for initial therapy, as well as transitioning, but it’s all people who then suppress and then get to the injectable agent.

Currently, the FDA application was tabled because of manufacturing issues. Apparently, it is being tested all the way down to 12-year-olds. Hopefully, if the manufacturing issues can be worked out, we’re talking about every 8 weeks per injectables for a treatment, which for some people, not everybody, will be a game changer.

There are long-acting oral agents that we’re hearing; exciting MK-591 coming from Merck & Co Inc as well as other ones. There are also injectables with the new class; capsid inhibitors, monoclonal antibodies. The treatment landscape is changing for the better. Other options will be subcutaneous and possible pumps, implants, and patches. It’s similar to the implant for birth control, for treatment as well as prevention. It is worth mentioning because cabotegravir in particular is in huge trials for prevention.

We will be talking about something very different very soon, and access will then be the question.

Colleen Kelley, MD, MPH: And cost.

Allison Agwu, MD, ScM: And cost. Particularly when we can suppress anybody practically, right? It is 90% suppressed on oral agents. The discussions we’ll have to have on how and who and where are going to be very important. It doesn’t mean we shouldn’t have those discussions, because for the people who are living with HIV, these are maybe lifesaving, game-changing remedies for them.