In this month’s ANA Q&A Membership Spotlight, we interviewed Beau M. Ances, MD, PhD, MSc who talks about the research that has gone into HIV medicine, cognitive issues for those who are HIV positive and getting older, and how his lab’s work can be used to study the COVID-19 virus.
1. What does the public need to understand about HIV medicine that it often doesn’t?
I think a lot of people still don't realize that many individuals who are HIV positive develop neurological deficits. Currently 30-50% of all persons living with HIV have cognitive deficits despite the introduction of combination anti-retroviral therapy. We continue to see individuals with cognitive deficits across the lifespan. HIV associated neurocognitive disorder (HAND) can be seen in older persons living with HIV. It is critically important to understand that more than 50% of all HIV positive individuals seen in infectious disease clinics in the US are now greater than 50 years old. This is radical change in our approach as HIV used to be considered a fatal disease but now the lifespan of many HIV positive individuals is similar to HIV uninfected people. The question many of these individuals, especially older persons living with HIV, are asking what is going to happen to my brain. We know that HIV can accentuate or accelerate the aging process in other organs. Many older HIV+ individuals are asking if they will develop Alzheimer’s disease.
2. How are treatment options for HIV different today from 10 years ago?
Treatment options for HIV positive individuals have greatly changed over the past 10 years. In the past HIV positive individuals had to take a large number of medications throughout the day. Now, we have combination anti-retroviral therapies that allow us to combine multiple medications into a single pill that is taken once a day. This has greatly reduced the pill burden for HIV positive individuals. It has also changed our goals for treatment of HIV positive individuals. We are now trying to achieve the 90-90-90 paradigm. We are trying to have 90% of individuals know their diagnosis, of this group 90% are on antiretroviral therapy, and from this group 90% of those individuals will have an undetectable viral load. Our goals are now to provide access to testing so that if an individual is diagnosed with HIV this person can quickly start on therapy. What is even more remarkable is that we are giving precision medicine to individuals who are diagnosed with HIV. If an individual is diagnosed with HIV we also know if this individual has a strain that is resistant to certain medications. Based on their genotype we can then tailor their therapy.
3. What promising research is poised to change the standard of treatment for HIV?
In the past we used to see HIV positive individuals with more severe forms of cognitive impairment- HIV associated dementia. With the introduction of combination anti-retroviral therapy we are now seeing more milder forms of impairment. The question that remains is why do some individuals continue to have cognitive impairment. One possibility is that viral reservoirs, specifically in the brain, can occur. The ability to detect these reservoirs will be important for any cure strategies that are being proposed. Our team and others are developing methods to image these reservoirs and evaluate potential cure strategies.
4. What work is your lab undertaking to move understanding or treatment for HIV forward?
We're very interested in developing novel non-invasive biomarkers to assess the effects of HIV and other comorbidities in persons living with HIV. More recently developed neuroimaging methods allow us to map brain networks in HIV positive individuals and compare them to HIV uninfected individuals. We have observed that multiple brain networks are involved but there remains significant heterogeneity in HIV positive individuals. This may help us tailor appropriate cognitive interventions for an individual.
We have also been utilizing novel positron emission tomography methods to visualize residual inflammation that may still occur in HIV positive individuals on combination anti-retroviral therapy. These neuroimaging biomarkers or readouts, could be added to our existing armamentarium to help in diagnosing individuals as well as evaluate potential adjunctive therapies to combination anti-retroviral therapies. These imaging biomarkers will also help us evaluate potential cure strategies with regards to the brain.
In addition, HIV positive individuals are living longer and could be at risk for developing Alzheimer’s disease. We have used multiple positron emission tomography methods to look at the hallmarks of Alzheimer’s disease – amyloid and tau. Using both of these techniques we have not seen an increase in either amyloid or tau in HIV positive individuals. We have also focused on additional comorbidities such as cardiovascular mechanisms and have seen important contributions of these factors to the development of cognitive impairment. These are potentially modifiable risk factors. We are in fact conducting a clinical trial to study the effects of exercise on cognition in persons living with HIV.
5. How has the ANA supported your career and/or work in this area?
The ANA has been invaluable for me success. I was fortunate enough to have received a K-Award and was able to attend ANA sessions for K awardees. I also attended a summer clinical trials workshop through the ANA where I was able to meet with key leaders in the field and learn important lessons needed to conduct studies. I have continued to attend ANA meetings. These are excellent forums to meet leaders in the field and learn about cutting edge research. I have been also able to give back to the ANA. I am currently the co-chair for the interactive lunch work-shop topic group where we are able to present focused sessions on key neurological areas. I find it very rewarding as I am able to teach and guide thoughtful discussions by future leaders in neurology.
6. Has the COVID-19 pandemic changed how you work?
Right now, this is an unprecedented time for neuro- infectious disease physicians like myself. We have created a post COVID-19 neurology clinic at Washington University in Saint Louis where we are evaluating individuals for subacute and chronic neurological changes due to the virus. We are actively developing novel biomarkers to help in diagnosing neurological complications. We are ideally suited to see these patients as we already have strong ties with infectious disease physicians. In fact, many of the AIDS Clinical Trials Group (ACTG) sites are also involved in vaccine trials and we are able to help them evaluate for neurological complications. This has provided myself, other colleagues here at Washington University in Saint Louis, and more junior members to study this virus and how it affects the brain. This is also a really great opportunity for residents and students to become more involved in neuro-infectious disease at an institution like ours.