10 Changes in HIV care that are revolutionizing the field

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Fourth–Generation HIV test: The new test adds p24 antigen to the HIV antibody test to permit detection of the disease before seroconversion, which is when the Western blot (WB) becomes positive. It can detect HIV during the early acute retroviral syndrome stage at Fiebig stage 2, unlike the WB results, which require waiting for 2–3 months after viral transmission at Fiebig stage 5.
Point–of–Care HIV viral load testing: Point–of–care (POC) HIV testing has been extremely successful as a screening tool to detect HIV. Now, there is a POC CD4 count test that permits staging HIV at the site of care, and it is anticipated that a POC viral load test will also be available, although the timeline for this development is unclear.
Early HIV therapy to achieve “Functional Cure”: There is now good evidence to show that the HIV reservoir with chronic HIV infection is substantial and is probably an important factor in immune activation and our inability to achieve cure, despite viral suppression with traditional monitoring. Note that “cure” is now described in two categories: a “sterilizing cure,” in which the virus is eliminated, and a “functional cure,” in which the virus continues to be present but does not require antiretroviral therapy (ART) for viremic control.
Preventing HIV infection: The HPTN 052 trial showed that “treatment is prevention” presumably because HIV infection, like virtually all infections, obeys the rule that probability of transmission is directly correlated with inoculum size. Pre–exposure prophylaxis (PrEP) is a newer option and seems to work in clinical trials, but the challenge of adherence may make it more difficult to implement in practice.
Eliminating the Hepatitis C coinfection cohort: It is estimated that 30–35% of persons with HIV infection also have hepatitis C infection. In the United States, hepatitis C infection is the major cause of liver failure, liver transplant and liver death, with an annual mortality that now exceeds that of HIV. The sudden and dramatic change in hepatitis C management is now virtually guaranteed, with an extraordinary array of new drugs expected to cure the majority of hepatitis C–infected patients.
P4P4P to address the Gardner HIV cascade challenge: P4P4P, or “pay for performance for patients,” which provides financial or other reward for patients to get tested, engage care, stay in care, and achieve viral suppression. It is now being studied in a controlled trial in Washington, DC, and Bronx, New York.
New approaches in HIV therapeutics on the horizon: There will always be a need for new antiretroviral agents owing to resistance and toxicity, but the small number of new drugs in the pipeline possibly reflects the adequacy of the current supply of 28 FDA–approved agents as well as the anticipated rush to generics.
Redefining the HIV provider: One of the key issues is defining who will be the HIV care provider. Will it be done primarily by an HIV specialist, will HIV be enveloped within primary care, or will there be some sort of mix, as with diabetes?
Evolving ethical issues in HIV care: The ethics of HIV care under healthcare reform is a good example of an evolving controversy that is likely to have an important impact on HIV drug selection in the future. It is very reminiscent of the highly quoted 1993 editorial by Marcia Angell, former editor of the New England Journal of Medicine, which stated that the doctor had become a “double agent,” considering our sometimes conflicted obligation to both the patient and the payer.
Generic drugs for HIV: There is great pressure for the use of generic drugs for HIV treatment, as for all medical conditions.