Clinical Insights into New Treatment Options for HIV: Cabenuva and Vocabria

Saro Arakelians, PharmD

HIV is currently not curable but can be controlled with effective treatment options to allow patients to live a healthy life with better quality.

HIV is a virus that attacks the human body’s immune system and if not treated, it leads to AIDS. HIV is currently not curable but can be controlled with effective treatment options to allow patients to live a healthy life with better quality.

The virus is believed to come from chimpanzees in Africa after being transmitted to humans, and the transmission of this type of virus (simian immunodeficiency virus) came from hunting these animals for meat. According to some data, transmission goes back to the 1800s and has been recorded in the United States since the early 1970s.¹

Approximately 1.2 million people in the United States live with HIV and about 14% of them (almost 1 in 7) may not even know they have the virus, making testing essential. This virus is more common in racial and ethnic minorities, as well as in gay and bisexual men. Nearly 36,000 new HIV infections occurred in the United States in 2018 alone, and the highest prevalence of this infection continues to happen in the southern regions of the country.²

The infection can be diagnosed using blood or saliva testing, such as antigen or antibody testing, as well as nucleic acid tests (NATs). Some of these tests may take few weeks for the results to be produced. For some patients, additional testing may be needed to confirm the diagnosis. Based on these tests, providers can monitor the progress of the disease as well as determine the best course of treatment for each individual patient.

There are also other tests that can determine the stage of the disease, including CD4 T cell counts and viral load testing. Furthermore, drug resistance tests can determine whether the patient has resistance to other drugs. For such patients, the health care provider may also conduct other tests for tuberculosis, hepatitis B, hepatitis C, sexually transmitted infections, liver and kidney function, cervical and anal cancer labs, cytomegalovirus, and toxoplasmosis.³

When it comes to the treatment options, there is currently no cure for HIV-infected patients or individuals with AIDS. Once the person is infected, the infection will not leave the human body and will infect it forever.

However, there are medications that can control the infection and keep the virus somewhat under control, including antiretroviral therapy (ART). Many patients diagnosed with this disease, regardless of the stage of the infection and complications, can begin therapy with ART.³

The ART regimens usually include a combination of 3 or more medications from various drug classes to fight against the virus. Some of these medication options are available as a single tablet combination that can be taken once daily. The goal of these drugs is to fight against the drug-resistant virus, to stop future resistance, as well as to maximize suppression of the virus in the blood.³

The various classes of HIV infection medications include non-nucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs), protease inhibitors (PIs), integrase inhibitors, and fusion inhibitors. Examples of NNRTIs include efavirenz, rilpivirine, and doravirine. Examples of NRTIs include abacavir, tenofovir disproxil fumerate, emtricitabine, lamivudine, and zidovudine.

Examples of protease inhibitors include atazanavir; darunavir; and the combination lopinavir and ritonavir. Examples of integrase inhibitors include the combination bictegravir, emtricitabine, and tenofovir alafenamide; raltegravir; and dolutegravir. Lastly, examples of fusion inhibitors include enfuvirtide and maraviroc.³

Any patient diagnosed with HIV should start receiving antiviral medications. Effective ART therapy can result in undetectable HIV viral load in the blood, which is currently the best outcome for these patients.

In order to achieve these goals, patients should be reminded to take their medications as scheduled, to be careful to avoid transmitting the disease, and to keep their immune system as strong as possible. Mental health and substance use issues should also be reviewed since they can impact the successful treatment outcomes.

Some treatment-related adverse effects can include nausea, vomiting, heart disease, weakened bones, high blood sugar, and cognitive or emotional problems. Health care providers can measure patients’ viral load and CD4 T cell counts to determine their response to therapy while considering adverse effects, whether to switch therapies, and when to stop the medication if need be.

Among the newest medications for HIV infections, the FDA recently approved cabotegravir and rilpivirine (Cabenuva, ViiV Healthcare), the first injectable regimen for HIV-infected adults, as a monthly injection. Officials also recently approved an oral form of cabotegravir (Vocabria) to be used with rilpivirine 1 month prior to starting therapy with Cabenuva injections.

Recommended dosing with Cabenuva is to begin with cabotegravir 30 mg once daily and rilpivirine 25 mg once daily, then to start Cabenuva 600 mg and rilpivirine 900 mg injection from the second month forward. Health care providers should evaluate the appropriateness of each patient for this therapy, taking into consideration injections, refrigeration, dosing intervals, and adverse effects.⁴

HIV and AIDS treatment has come a long way since azidothymidine was introduced in the 1980s. Now, with oral treatment options and the arrival of new monthly injectables on the market, we are beginning to see new horizons for treating patients with HIV. Such new therapies promise a better outcome and improved quality of life for those who need these medications for a lifetime.

REFERENCES

  1. About HIV. Centers for Disease Control and Prevention; Reviewed April 7, 2021. https://www.cdc.gov/hiv/basics/whatishiv.html. Accessed May 5, 2021.
  2. US Statistics. HIV.gov; Updated March 17, 2021. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics. Accessed May 5, 2021.
  3. HIV/AIDS. Mayo Clinic; February 13, 2020. https://www.mayoclinic.org/diseases-conditions/hiv-aids/diagnosis-treatment/drc-20373531. Accessed May 5, 2021.
  4. Murray M. Injectable Antiretrovirals Are Now FDA-Approved: Here’s What You Need to Know. GoodRx; January 22, 2021. https://www.goodrx.com/blog/cabenuva-injectable-hiv-antiretroviral-almost-here/#:~:text=On%20January%2021%2C%202021%2C%20the,1%20month%20before%20starting%20Cabenuva.. Accessed May 5, 2021.