HIV Therapy and Prevention

HIV care is a top concern for many infectious disease specialists in the United States. In light of World AIDS Day and the latest recommendation for PrEP therapy, we caught up with Dr Richard Chaisson about HIV therapies and prevention.

Richard Chaisson, MD, is a professor of medicine at Johns Hopkins University School of Medicine, director of Johns Hopkins Center for Tuberculosis Research, and principal investigator at Johns Hopkins Center for AIDS Research. 

Consultant360: Tuberculosis-HIV co-infection is common. How can TB be prevented in patients with HIV to lower the burden of the disease and increase quality of life?

Richard Chaisson: Co-infection is very common in Africa, Asia, and Latin America. The best strategy for reducing the burden of disease is to give TB preventive therapy and antiretroviral therapy (ART) to patients at risk. Research has shown that the combination of ART and TB preventive therapy lowers the risk of TB substantially.

C360: Are there any drug-drug interactions between TB therapy and HIV therapy? What do the guidelines say about treating both simultaneously?

RC: Yes, the TB drug rifampin is notorious for lowering concentrations of a number of drug classes, including ART drugs such as protease inhibitors, integrase inhibitors, and non-nucleoside reverse transcriptase inhibitors. The newer drug rifapentine, a key drug for preventive therapy, has similar effects. We now know that rifampin can be safely administered to patients on the ART drugs efavirenz and raltegravir, and can also be used with dolutegravir if the dose of that drug is doubled. Rifapentine can be used with efavirenz. Since efavirenz and dolutegravir are now the most widely used ART drugs, options are available.

C360: Pre-exposure prophylaxis (PrEP) therapy is becoming more mainstream in the media, raising awareness for prevention of HIV. And the USPSTF has recently recommended PrEP therapy to all at-risk populations. What are your thoughts on these progressions to better control, and eventually eliminate, HIV in the United States?

RC: PrEP is an important intervention, but no one strategy will lead to elimination of HIV in the United States or globally. A combination of approaches, including behavior change, use of condoms, and PrEP for those at risk, as well as providing ART to all infected individuals which greatly reduces the risk of transmitting HIV, is necessary if we hope to achieve control of the epidemic.

C360: What knowledge gaps exist amongst infectious disease specialists when it comes to HIV treatment and prevention?

RC: While most infectious disease specialists are very comfortable prescribing and monitoring ART, many lack experience with PrEP. More knowledge about successful approaches to identifying patients who would benefit from PrEP and methods for initiating and monitoring PrEP are needed.

C360: What are the top takeaways infectious disease specialists need to know about PrEP therapy?

RC: PrEP works and is safe, but requires outreach, patient education, and monitoring.