HIV expert and Consultant Physician Prof Marta Boffito speaks to Niamh Quinlan about developments regarding long-acting HIV treatment and the importance of resilience in delivering care.
Waking up every morning to take medication can remind people with HIV (human immunodeficiency virus) of their infection.
Long-acting injectables, which can be administered in HIV clinics once a month, or once every two months, can be freeing for these patients, according to HIV expert and Consultant Physician at the Chelsea Westminster Hospital, UK, Prof Marta Boffito.
“The biggest and the most important aspect of this treatment is the fact that people living with HIV who have to take pills every single day of their lives can take injectables and feel free from… taking pills every day,” she said.
Prof Boffito leads the Clinical Research Facility and is the HIV Service Director at Chelsea and Westminster, where she runs numerous research projects and clinical trials. She also lectures in HIV medicine and pharmacology at Imperial College London, as well as in various national and international settings.
On 19 May, Prof Boffito spoke on long-acting HIV treatment during a symposium at an Infectious Diseases Society of Ireland meeting in Croke Park, Dublin.
The cabotegravir long-acting injection in combination with rilpivirine long-acting injection is now accessible to people who have HIV. The treatment officially launched in Ireland in the middle of June. A phase III trial of the treatment had taken place in Ireland with a small number of participants.
According to GlaxoSmithKline (GSK), which owns ViiV Healthcare, the developers of cabotegravir, the two-drug combination reduces the number of days patients receive treatment from 365 to six days per year, when on the continuation injection phase of treatment.
“We’ve been talking to people in clinical trials who have been receiving them for a while,” Prof Boffito said. “They absolutely loved them. They say they would never go back to pills; they say they much more prefer an injection either every month or every other month.”
However, she acknowledged that some patients prefer to take medication daily in pill form. This option is still available to those who are eligible. Patients eligible for the long-acting injection combination are those who are immunologically suppressed and on a stable antiretroviral regimen. On these regimens, patients must not have present or past evidence of viral resistance to, and have no prior virological failure with, agents of the non-nucleoside reverse transcriptase inhibitor and integrase inhibitor class of antiretrovirals.
As patients would receive the injection in clinics every month or other month, some structural changes within the clinics is needed to deliver the treatment.
“Today, we see people living with HIV in clinic twice a year, usually because that’s when they come in to do their blood tests and receive their script,” said Prof Boffito. “When someone is on an injectable, they needed to attend the clinic every other month.
“We have to work to restructure a little bit how we work here. And I think it is up to the clinic to be clever and make sure that the restructuring is cost-effective, cost-beneficial and efficient. And again, meet the needs of the patients.”
She referenced a 2021 European study published in HIV Medicine and a ViiV Healthcare-funded US study in 2021 in the Journal of the International AIDS Society.
These showed initial hesitancy from healthcare workers around resourcing and restructuring of clinics when administering long-acting injections. However, after a few months of implementation, these concerns decreased “remarkably”.
Prof Boffito said: “I have to be honest with you, really this [concern around resources and restructuring] is not good reason enough. We’re very resilient. There is much more than an injection every other month that scares us. I think this is really important to know that.”
A takeaway message is that “HIV treatment is not as complicated as it used to be. It has changed remarkably.”
EQUITY OF CARE
Reflecting on the Covid-19 pandemic and treating immunocompromised people in a time of remote healthcare, Prof Boffito said there were “definitely points to reflect on” with regards to health equity.
During Covid, “we really learned…how to make sure that we get better at that,” she said.
“It [equity of care] is something that is at the top of our mind when we treat HIV. But Covid highlighted other aspects. Access to chronic treatment was a struggle for some people; we need to understand who are these people, and why it was a struggle for some people and not for others.”
Prof Boffito said she is conducting interviews with focus groups comprising people from minority communities, who are living with HIV, to ascertain their treatment experiences during the pandemic. She said that what healthcare workers and HIV clinic workers believe is the best form of access
for patients “is not true for all cultures in all social situations”.
“We are involving people living with HIV belonging to different populations, asking them what they want, what they need, and how to ensure that [isolation and lack of access] doesn’t happen,” she said.
“One group will want an app, one group will want an email, one group will want a phone call, [it is] as simple as that. But if we don’t ask them, we don’t know.”
In 2009, Prof Boffito also began a HIV clinic for people aged above 50 to manage comorbidities and prevent potential complications and frailty in older patients. The clinic conducts research and provides “individualised, patient-focused care, because it’s the most complex cases that need more time and thinking”, the Professor added.
Prof Boffito said operations may be disrupted due to the recent outbreak of monkeypox.
As of late June, there were 39 confirmed and notified cases of monkeypox infection in Ireland and over 1,200 in the UK.
Following Covid, it is another infection that has put those who are immunocompromised at risk.
For clinics to deal effectively with this latest outbreak, Prof Boffito said it goes “back to resilience”.
“We’re learning at the moment,” she said. “We are very busy and have to reorganise our clinic sexual healthcare delivery, make sure that our immunocompromised people are informed and looked after.”
However, Prof Boffito said that this outbreak is “nothing as bad as Covid”.
“To be honest with you, it’s almost like we crossed the line and there is nothing that should stop us to provide the best care we can for our patients,” she said. “But we need to implement injectables [ for HIV treatment]. I don’t think that we should use anything as an excuse. We are managing the outbreak and starting to prescribe injectables at the same time.”