Looking Ahead: HIV Medications in the Pipeline

The medications used for treating HIV have been refined for more than 25 years and work well. But what about the next 25 years? Monica Gandhi, MD, MPH, an infectious disease doctor and professor of medicine at the University of California–San Francisco (UCSF) talks about the current research efforts she is most excited about and looks ahead at the HIV medications in the pipeline that could potentially change the future of HIV treatment and management.

This Q&A was originally featured in First Report Managed Care and has been edited for length and clarity. For the full interview, please visit the First Report Managed Care.

First Report Managed Care: Regarding current research efforts, what are you most excited about?

Monica Gandhi, MD, MPH: The FDA approved the first long-acting injectable in 2021. It was probably eclipsed by everything else going on in the world, but it was a huge advance. Cabetogravir and rilpivirine is a once-monthly regimen that can be administered intramuscularly.

Now, I want to talk about this treatment. The one concern with its approval and rollout is that its inclusion criteria for both the registrational trials required a relatively adherent population, as do the package inserts.

What I mean by that is the registrational trial with cabotegravir and rilpivirine required at least 16 weeks of being suppressed on an oral regimen. There is a 4-week oral lead-in before we can administer the injectables.

What we do not have guidance on is how to use these injectables in poorly adherent patients, which are the populations that we are still struggling to treat. We are doing a pilot at Ward 86 to try to administer these injectables in patient populations that struggle with adherence.

There is so much coming up that I think could be a treatment possibility for these patients. I am most excited about the even longer-acting formulations.

We hope to someday treat people with once-every-6-months therapies, as with lenacapavir, which is the capsid inhibitor that is coming.

Then, we need to pair lenacapavir with something else, as we never do monotherapy for HIV. One possibility for combination therapy would be another new agent called islatravir. There is a possibility of administering them every 3 months or every 6 months together. We already have that formulation for lenacapavir.

Lenacapavir and islatravir are both being studied as preventative agents. Cabotegravir is already being assessed as a preventative agent and has been filed with the FDA. It is an incredible time in HIV medicine. Even though COVID-19 set us back with some of our outcomes, the progress has been increasing.

First Report Managed Care: Given this progress, where do you see the future of care going?

Dr Gandhi: HIV care providers hope that we will one day be able to either administer treatment every 6 months by a subcutaneous injection, or prevention every 6 months in the same way.

There is also a possibility of a once-yearly preventative agent with islatravir. There is this dream shimmering on the horizon that we could give people islatravir as an implant once annually, and patients will have long-standing prevention for that entire year.

Anything that extends the interval between treatments for hard-to-reach patients makes it even more exciting. But it is imperative that long-acting medications are studied in hard-to-reach populations. That is my only worry.

About Dr Gandhi

Monica Gandhi, MD, is an infectious disease doctor and professor of medicine at the University of California–San Francisco (UCSF). She is also the director of the Center for AIDS Research and the medical director of San Francisco General Hospital HIV Clinic Ward 86, which serves local publicly insured patients.