The use of combination antiretroviral therapy in patients with malignancies is associated with improved HIV and cancer-related outcomes. Combining antiretroviral and antineoplastic therapy is often complicated by significant drug-drug interactions, drug-disease state monitoring interactions and overlapping toxicities. Definitive pharmacokinetic studies evaluating drug interactions between antineoplastics and antiretrovirals are uncommon and clinical judgment must often be used to determine the potential for significant interactions. Adjusting antiretroviral therapy in response to significant drug interactions or overlapping toxicities is often more feasible than modifying antineoplastic protocols.
Abstract Long-acting injectables (LAIs) for HIV prevention and treatment could dramatically improve health outcomes and health equity for people with HIV and those who could benefit from pre-exposure prophylaxis. Despite widespread acceptability and demand by providers and potential users of LAIs, implementation has been extremely limited since the introduction of cabotegravir/rilpivirine, the first LAI for HIV treatment, in January 2021, and long-acting cabotegravir, the first LAI for HIV prevention, in December 2021. We report results of a provider survey, conducted by the HIV Medicine Association, which identified LAI implementation barriers related to health insurance processes, staffing and administrative support, drug costs and acquisition, and access for individuals who are uninsured. We provide policy recommendations to address those barriers and facilitate broad and equitable access to LAIs for HIV prevention and treatment, which will be necessary to achieve the goals of the US Ending the HIV Epidemic initiative.
We present a case report of a 62-year old female with HIV and chronic facetogenic back pain who underwent bilateral L3-L4 and L4-L5 medial branch nerve blocks using triamcinolone acetonide 80 mg. 2 weeks later she presented to the emergency department with acute anxiety/depression and was discharged with psychiatric follow-up. 2 weeks after this she presented to the outpatient HIV clinic with persistent uncontrolled depression alongside classic cushingoid features (e.g., buffalo hump, moon facies). She was diagnosed with iatrogenic Cushing syndrome caused by a drug-drug interaction between triamcinolone and ritonavir, a protease inhibitor and a CYP3A4 enzyme inhibitor. While the literature describes the interaction of ritonavir with intra-articular/intranasal/epidural triamcinolone, this is the first documented occurrence following a nerve block procedure. Symptoms resolved within 6 months alongside discontinuation of protease inhibitor therapy.Lay abstract We report a 62-year old woman with history of HIV and depression who developed Cushing syndrome, which is a state of steroid excess in the body, after a nerve block procedure for treatment of back pain. Her first symptoms were worsening anxiety and depression, causing her to go to the emergency department. Unfortunately, the relationship to the steroids was not identified at the time. Later, she developed increased fat deposition in her face and upper neck, which is characteristic of Cushing syndrome. The HIV medications responsible for this adverse event were determined to be ritonavir and darunavir, which are classified as protease inhibitors. Her symptoms improved within 6 months in association with discontinuation of ritonavir and darunavir. This is the first known case of Cushing syndrome following a nerve block procedure for back pain, although previous cases have documented this occurrence following other forms of steroid treatments.
Abstract The HIV epidemic continues to pose a significant burden on the healthcare system. Although the incidence of annual new infections is decreasing, health disparities persist and most new infections remain concentrated into different racial, ethnic, and minority groups. Pre‐exposure prophylaxis (PrEP), which involves those at high risk of acquiring HIV to take chronic medications to prevent acquisition of the virus, is key to preventing new HIV infections. The purpose of this article is to review medication therapies for PrEP and examine their role in personalizing PrEP in different patient populations. Additionally, new medications currently under development for PrEP are reviewed, as well as treatment as prevention (TasP) and post‐exposure prophylaxis (PEP). There are currently four medications available for PrEP: the oral options of co‐formulated emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) or emtricitabine/tenofovir alafenamide (FTC/TAF); injectable long‐acting cabotegravir (CAB‐LA); and the vaginal ring dapivirine (DPV‐VR). FTC/TAF is not currently indicated for persons at risk for HIV through vaginal sex due to lack of studies, but trials are currently ongoing. DPV‐VR is available in Zimbabwe and South Africa and has been endorsed by the World Health Organization but is not currently available in the United States. Several agents are also in development for use in PrEP: the novel long‐acting injectable lenacapavir, a first‐in‐class capsid inhibitor, which has no cross‐resistance to any existing HIV drug class; the subdermal implant islatravir, a first‐in‐class translocation inhibitor; and VRC01, a broadly neutralizing antibody (bnAb) which has been evaluated in proof‐of‐concept studies that may lead to the development of more potent bnAbs. Overall, PrEP is highly effective at preventing HIV infection in high‐risk populations. Identifying optimal PrEP regimens in different patient populations is complex and must consider patient‐specific factors and medication cost and access considerations. Lastly, providers should consider individual patient preferences with regard to prevention to improve access, retention in care, and adherence.