By the time Pablo* walked into the Emory Infectious Diseases Clinic in late 2021, his HIV was so advanced that I suspected he had developed at least two opportunistic infections and needed emergent chemotherapy for one of them. He was in his early 20s, Latino and representative of the HIV epidemic in the Southeast in the post-COVID world.
As a Latina and bilingual infectious diseases physician in Atlanta, a growing percentage of my patient panel consists of patients like Pablo. The COVID-19 pandemic wreaked havoc on healthcare systems throughout the United States, including in Metro Atlanta. Public health departments shifted their focus and resources to combat COVID-19 and people avoided routine care, including HIV testing. As a result, there was a 17% decrease in HIV diagnoses reported nationally to the CDC in 2020 compared to 2019, along with a decline in HIV testing in priority populations (including Black or African American men who have sex with men [MSM] and Hispanic/Latino MSM).1
Locally, the Georgia Department of Public Health (DPH) estimates that over 400 fewer HIV diagnoses were reported in 2020 compared to 2019. As of the latest reported data in 2022, they have yet to see the full rebound of HIV diagnoses that were missed during the pandemic. This is particularly significant since Georgia ranked second in the nation in the rate of HIV diagnoses among adults and adolescents during 2022.2
As we continue to work to bridge this gap in HIV diagnoses in Metro Atlanta, it is vital to remain vigilant about testing. The CDC recommends that all adolescents and adults age 13-64 years be tested for HIV at least once, with annual rescreening for those who report behaviors that increase the risk of acquiring or transmitting HIV.3
In my practice, I care for a handful of patients, all Black women, who were diagnosed after the age of 64 following extensive testing for alternative etiologies of their presenting symptoms. Another subset of my patients, all Black or Latino adolescents identifying as MSM, were referred to me after seeing several other subspecialists for what turned out to be symptoms of acute HIV. These cases highlight the ongoing need for a low threshold to screen all patients for HIV at least once, regardless of age or background, and continually reassess the need for rescreening.
For people living with HIV (PLWH), out of the shadow of the COVID-19 pandemic emerged the most innovative treatment option in a generation: long-acting injectables (LAI). The most popular option available currently is Cabenuva, a two-drug co-packaged product of two different classes of antiretrovirals (cabotegravir and rilpivirine) administered as two extended-release injectable suspensions.
Initially approved in January 2021 as a once monthly treatment for virologically suppressed adults (those having an HIV-1 RNA less than 50 copies per milliliter [c/ml]) with an oral lead in, it is now approved for administration every two months and the oral lead in made optional.4-6
While the decision to start LAI must continue to be weighed carefully in consultation with an HIV provider, it has proven to be life-changing for many PLWH who have lived with the stigma of taking daily antiretrovirals for an HIV diagnosis. The use of LAI continues to evolve, potentially serving as a life-saving tool for achieving virologic suppression among PLWH who have not previously been suppressed and face adherence challenges.7
The spectrum of use for LAI in the post-pandemic world extends beyond treatment, as extended-release injectable cabotegravir has also been approved for HIV pre-exposure prophylaxis (PrEP) under the name Apretude. Like Cabenuva, Apretude is approved for use in cisgender men, women and transgender women who have sex with men and is administered every two months with an optional oral lead in.8
The national rollout of LAI for PrEP has been slow due to logistical factors, including complexity of follow-up and cost effectiveness compared to oral PrEP. Yet its use continues to evolve as clinics across the country implement novel strategies to reduce barriers for use in priority populations in an effort to make strides to end the HIV epidemic.9
With the most challenging years of the COVID-19 pandemic behind us, our national focus must shift back to achieving the primary goal of the CDC’s Ending the HIV Epidemic in the U.S. initiative – reducing new HIV infections in the United States by 90% by 2030.10 Here in Atlanta, this means continuing to advocate for and innovate in both prevention and treatment of HIV so that all those in need of care can access it without significant barriers. So that patients like Pablo can continue to live healthy, happy lives and so that so many others in our city can live free of HIV.
References
1. DiNenno EA, Delaney KP, Pitasi MA, MacGowan R, Miles G, Dailey A, Courtenay-Quirk C, Byrd K, Thomas D, Brooks JT, Daskalakis D, Collins N. HIV Testing Before and During the COVID-19 Pandemic – United States, 2019-2020. MMWR Morb Mortal Wkly Rep. 2022 Jun 24;71(25):820-824. doi: 10.15585/mmwr.mm7125a2. PMID: 35737573.
2. Georgia Department of Public Health, HIV Epidemiology Section, 2022 HIV Surveillance Summary, Georgia, https://dph.georgia.gov/epidemiology/georgias-hivaids-epidemiology-section/hivaids-case-surveillance, Published March 2024, [Accessed: August 19,2024]
3. Branson BM, Handsfield HH, Lampe MA, et al.; CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(No. RR-14):1–17. PMID:16988643s
4. (2021, January 27). FDA Approves Cabenuva and Vocabria for the Treatment of HIV-1 Infection. FDA. Retrieved August 23, 2024, from https://www.fda.gov/drugs/human-immunodeficiency-virus-hiv/fda-approves-cabenuva-and-vocabria-treatment-hiv-1-infection
5. (2022, March 24). ViiV HEALTHCARE ANNOUNCES LABEL UPDATE FOR ITS LONG-ACTING HIV TREATMENT, CABENUVA (CABOTEGRAVIR, RILPIVIRINE), TO BE INITIATED WITH OR WITHOUT AN ORAL LEAD-IN PERIOD. ViiV. Retrieved August 23, 2024, from https://viivhealthcare.com/en-us/media-center/news/press-releases/2022/march/viiv-healthcare-announces-label-update-for-its-long-acting-hiv/#1
6. Orkin C, Bernal Morell E, Tan DHS, Katner H, Stellbrink HJ, Belonosova E, DeMoor R, Griffith S, Thiagarajah S, Van Solingen-Ristea R, Ford SL, Crauwels H, Patel P, Cutrell A, Smith KY, Vandermeulen K, Birmingham E, St Clair M, Spreen WR, D’Amico R. Initiation of long-acting cabotegravir plus rilpivirine as direct-to-injection or with an oral lead-in in adults with HIV-1 infection: week 124 results of the open-label phase 3 FLAIR study. Lancet HIV. 2021 Nov;8(11):e668-e678. doi: 10.1016/S2352-3018(21)00184-3. Epub 2021 Oct 14. PMID: 34656207.
7. Gandhi M, Hickey M, Imbert E, Grochowski J, Mayorga-Munoz F, Szumowski JD, Oskarsson J, Shiels M, Sauceda J, Salazar J, Dilworth S, Nguyen JQ, Glidden DV, Havlir DV, Christopoulos KA. Demonstration Project of Long-Acting Antiretroviral Therapy in a Diverse Population of People With HIV. Ann Intern Med. 2023 Jul;176(7):969-974. doi: 10.7326/M23-0788. Epub 2023 Jul 4. PMID: 37399555; PMCID: PMC10771861.
8. Liegeon G, Ghosn J. Long-acting injectable cabotegravir for PrEP: A game-changer in HIV prevention? HIV Med. 2023 Jun;24(6):653-663. doi: 10.1111/hiv.13451. Epub 2022 Dec 5. PMID: 36468218.
9. Liu AY, Buchbinder SP. CROI 2024: Global Epidemiology and Prevention of HIV and Other Sexually Transmitted Diseases. Top Antivir Med. 2024 Jul 17;32(3):447-482. PMID: 39142289; PMCID: PMC11293602.
10. (2024, March 20). Ending the HIV Epidemic in the US Goals. CDC. Retrieved August 23, 2024, from https://www.cdc.gov/ehe/php/about/goals.html
