As anti-retroviral therapy (ART) has significantly advanced, the focus of human immunodeficiency virus (HIV) treatment has shifted towards safer and more effective long-term care.

With the life expectancy of HIV-positive individuals now similar to that of non-infected individuals thanks to the widespread availability of ART, there is a growing emphasis on managing comorbidities and drug interactions associated with aging.

This transition reflects a broader strategy where the suppression of the virus is no longer the sole objective as maintaining overall health and mitigating other conditions has become equally crucial.

In light of these changes, Korea Biomedical Review recently met with Professor Anton Pozniak, a global HIV/AIDS expert, to talk about the current and future of HIV management and treatment.

Pozniak has been at the forefront of HIV research since the early days of the HIV epidemic in the early 1980s. Pozniak's contributions to the field are profound, serving as a consultant physician in HIV Medicine at Chelsea and Westminster Hospital in London and an honorary professor of clinical research at the London School of Hygiene and Tropical Medicine.

Pozniak currently oversees the Test & Treat Project in Tanzania and has served as the president of both the International AIDS Society (IAS) and the European Treatment Network for HIV, hepatitis, and Global Infectious Diseases (NEAT-ID).

He also chaired the committee for the British HIV Association (BHIVA) that established clinical guidelines for tuberculosis/HIV management.

The British expert stressed that this demographic shift underscores the importance of managing comorbid conditions alongside HIV.

Pozniak noted the increasing number of aging HIV-positive individuals, especially in countries like the U.K., where over 50 percent of HIV patients are now over 50 years old.

"In the U.K., cardiovascular diseases and mental health disorders are notably higher among HIV patients," Pozniak explains. "Lifestyle factors, poverty, and the psychological impact of living with HIV contribute to this."

In light of these challenges, ART options like Gilead Sciences' single-tablet regimen, Biktarvy, have gained prominence.

Biktarvy has demonstrated consistent long-term safety and efficacy, with studies showing no cases of resistance-related treatment failures over five years and minimal adverse reactions.

"Biktarvy's safety profile and its effectiveness in maintaining low lipid levels are particularly important for long-term treatment," Pozniak said. "Real-world studies from Belgium and Italy corroborate these findings, showing stable lipid levels and even improvements in some metabolic parameters among patients."

In Belgium, a large-scale real-world study involving 2,001 HIV patients treated with Biktarvy observed no significant changes in lipid levels, such as triglycerides, HDL, and LDL.

Similarly, Italian cohort studies SCOLTA and BICTEL found no significant changes in TC/HDL ratios, and in some cases, there was even a decrease.

The importance of addressing drug-drug interactions in HIV care

A significant concern in HIV treatment is drug-drug interactions (DDIs), especially as patients age and require medication for other conditions. Biktarvy's favorable interaction profile with common medications like beta-blockers and calcium channel blockers makes it a preferred option.

Pozniak mentions that "unlike some HIV treatments, Biktarvy does not require dose adjustments with drugs like metformin," simplifying management for patients with comorbidities.

Moreover, the U.K. professor stressed that Biktarvy's ability to maintain viral suppression despite occasional lapses in medication adherence—a concept known as "forgiveness"—is crucial. In Italy, Biktarvy maintained viral suppression even in patients with adherence rates as low as 70 percent.

"This forgiveness effect is a significant therapeutic advantage, particularly for patients who struggle with strict adherence," Pozniak said.

Switching HIV treatments for managing comorbidities

When asked about switching HIV treatments to address comorbid conditions like dyslipidemia, Pozniak emphasized a cautious approach.

"Addressing lipid abnormalities by changing HIV treatments is generally not a preferred strategy," he said. "While switching from protease inhibitors (PIs) to second-generation integrase strand transfer inhibitors (InSTIs) can be considered, I would not recommend switching between same-class treatments like Biktarvy and DTG/3TC."

The therapeutic benefits from such switches are minimal in managing comorbidities like dyslipidemia, he added.

Instead, Pozniak highlights the findings from the REPRIEVE study, which demonstrated that statin therapy could reduce the risk of atherosclerotic cardiovascular disease (ASCVD) by 35 percent in HIV patients.

"Managing ASCVD risk through statins is far more effective than attempting to lower lipid levels by switching HIV treatments," he said. "Global guidelines also recommend this approach based on the REPRIEVE study's results."

When discussing HIV drug resistance, Pozniak acknowledged the concerns raised by the World Health Organization (WHO) in their recent report on the rising risk of drug resistance in long-term HIV treatment.

The report highlighted that in certain regions, particularly where large-scale ART programs are in place, the development of drug resistance could pose a significant challenge.

"The WHO report is a crucial signal that we need to closely monitor drug resistance patterns, especially in areas with high ART coverage," says Pozniak.

Pozniak emphasizes that while the WHO report highlights potential issues, it doesn't necessitate an immediate change in current HIV treatment strategies.

"The emergence of resistance is influenced by multiple factors, including treatment adherence, drug availability, and the specific ART regimens used," he said. "In regions like Africa, where ART programs cover vast populations, and logistical challenges can disrupt treatment continuity."

Pozniak stressed the importance of using high-resistance-barrier drugs like Biktarvy to mitigate these risks.

"The single-tablet regimen not only simplifies treatment but also ensures that patients receive all necessary components in one dose, reducing the chances of missed medications and subsequent resistance development," Pozniak said. "Maintaining the effectiveness of ART in these settings is crucial, and Biktarvy's properties make it a strong candidate for widespread use."