NCHIV2016 plenary speaker, Roy Gulick, on HIV treatment guidelines today and in the next 10 years

Roy Gulick.JPGDr Roy Gulick is Professor of Medicine at Weill Medical College of Cornell University and attending physician at the New York Presbyterian Hospital. In 1996, Dr Gulick presented the results of the first triple drug combination trial, which marked a major breakthrough in in treatment and outcomes, and he has since continued to research antiretroviral therapy strategies for HIV treatment and prevention. Dr Gulick is one of the invited plenary speakers at NCHIV 2016, where he will be talking about current HIV treatment guidelines and how these may look in 10 years’ time.

Why did you choose to specialise in HIV/AIDS?

I was a young medical student in New York just after the first cases of HIV/AIDS were reported in June 1981. I probably saw my first case in 1982 and, when I stayed on in New York for my internal medicine training, I saw a lot more people with AIDS. At the time, almost everybody died within a year or two and that had a profound impact on me, as did the stigma associated with this mysterious and unknown disease at the time. So, I felt that I needed to do something and decided to point my career in the direction of HIV/AIDS right from the beginning.

Obviously the big breakthrough in HIV treatment came with the introduction of combination antiretroviral therapy (cART) in 1996. The first NCHIV conference took place 10 years later in 2006 and this year, in 2016, we’re celebrating the 10th anniversary of NCHIV. Looking back over the last 10 years, have there been other milestones in HIV treatment?

Absolutely. There have been three big ones. One of the questions in the field since the beginning has been ‘what is the best time to start treating HIV?’. We now have definitive data to show that you should treat everyone with an HIV infection, regardless of their CD4 cell count or their clinical status. Everyone benefits from therapy. The second big thing is that treatment has improved enormously. 2006 is a notable year in the history of HIV treatment because that was the year that the first one-pill, once-a-day combination treatment came out. Over the last 10 years, the drugs have become more potent, less toxic and more convenient. This has led to delayed disease progression and improvements in survival, to the point that someone with HIV who is treated appropriately and early in their disease can expect to live as long as someone without HIV. Finally, we now know that treatment is highly effective in preventing transmission to other people; so, treatment is prevention.

What do you think HIV treatment will look like 10 years from now?

One-pill once-a-day works for most, but not all. At the moment, researchers are looking into long-acting preparations of antiretrovirals, such as injectables that are injected once a month or once every other month and that could replace oral pills. In addition, other new technologies such as implants are being explored. So the goal in the next 10 years is to make taking HIV therapy even easier than it is today with one-pill once-a-day regimens. If these techniques become proven and affordable, they may help reach those people who, for whatever reason, are unable to take daily medication. However, generic therapy is also very commonly used worldwide and I think this will also continue in the coming years, with some of the newer and better drugs. Lastly, new drugs will be developed with either new mechanisms of action or as better or safer preparations of the drugs that we have today.

What role do you see for HIV pre-exposure prophylaxis (PrEP) in the future?

PrEP is an example of how we can use HIV treatment to be effective in prevention. There have been a number of studies that show that if you give two drugs to an HIV-negative person who is at risk for HIV, the drugs can greatly reduce the risk of acquiring HIV infection. The US was the first country in the world to approve PrEP and I think physicians there have really embraced this strategy. PrEP is now also being rolled out in many other countries in the world to complement the existing prevention strategies. I would foresee us continuing to make progress and using PrEP in people who are at risk and want to protect themselves.

What will be the biggest challenges in terms of treatment in the coming years?

The latest recommendations say treat everyone. However, we know that while over 17 million people worldwide are taking antiretroviral therapy, a total of 37 million people have an HIV infection; so there’s still a large gap in terms of those who are receiving treatment and those who need treatment. Therefore, I think one big push in the coming 10 years will be to ensure access to treatment for everyone who’s HIV-infected. That’s a big, big challenge.

Furthermore, although we are making great progress in terms of treatment and new prevention strategies, people are still getting infected. If you look at worldwide figures, about a third of new infections are in people under the age of 24. And, if you look around the globe, two main groups represent increases in infection. In developed countries, including the US and Europe, it’s men who have sex with men (MSM), particularly under the age of 30. So young MSM are really at risk, but don’t perceive HIV as a threat anymore. This is completely the wrong message and we need to do better in that group. In other areas of the world, particularly eastern Europe, Russia, and Central Asia, injection drug users (IDUs) are a target population; in these parts of the world, the rates of HIV infection in IDUs are increasing dramatically. Stigma and discrimination, especially in these target populations, are a big problem. So although there’s good news, there is also the sobering news that we need to do better and not only fight for treatment, but also fight against stigma.