Ray’s Chief Complaint & History of Present Illness
A 29-year-old Caucasian man* with HIV-1 infection reports urethral burning and discharge.
- Symptoms began 3 days ago
HIV-1 diagnosed 2 years ago
- - HIV genotypic resistance test showed no mutations
- - Started on Tivicay® (DTG) 50 mg and Descovy® (FTC/TAF) at that time
Reports having trouble maintaining routines due to irregular travel and work schedule
Asks about single-tablet regimen options
*This is a hypothetical patient
DTG = dolutegravir; FTC = emtricitabine; TAF = tenofovir alafenamide
Descovy is a registered trademark of Gilead Sciences. Tivicay is a registered trademark of Viiv Healthcare.
Ray’s Personal & Social History
Sexual history: MSM
Occupation: Long-haul trucker
- Couch-surfs with friends and family when not on the road
No reported history of illicit drug use
MSM = men who have sex with men
Ray’s Physical Exam & Lab Tests
Pertinent physical findings:
- Purulent urethral discharge
- No genital lesions or inguinal adenopathy
- Fasting glucose: 85 mg/dL
- Fasting lipids:
- TC: 138 mg/dL
- LDL-C: 60 mg/dL
- HDL-C: 60 mg/dL
- Trig: 90 mg/dL
- Serum creatinine: 0.75 mg/dL
- AST and ALT: WNL
- HBV vaccinated
- HIV laboratory results
- Viral load (over past 12 months):
- CD4+ cell count: 410/mm3
- STD screening:
- Positive for gonorrhea
ALT = alanine aminotransferase; AST = aspartate aminotransferase; CD4+ = cluster of differentiation 4; STD = sexually transmitted disease
29-year-old man with HIV-1 infection and gonorrhea, at risk for suboptimal adherence with his antiretroviral regimen:
Diagnosed and treated for STD during this visit
Currently on an MTR; interested in STR options
MTR = multi-tablet regimen; STD = sexually transmitted disease; STR = single-tablet regimen
What potential factor(s) may support switching Ray to a different ARV regimen?
- Decrease pill burden
- Prior virologic failure
- Virologic suppression
- Suboptimal adherence
In addition to recommending patient counseling and scheduling a follow-up visit in 2-4 weeks, which of the following ARV regimens would you consider recommending for Ray?
- Biktarvy® (BIC/FTC/TAF)
- Odefsey® (RPV/FTC/TAF)
- SYMTUZA® (DRV/c/FTC/TAF)
- Triumeq® (DTG/ABC/3TC)
The DHHS guidelines state that the fundamental principle of regimen switching is to maintain viral suppression without jeopardizing future treatment options. The review of a patient’s full antiretroviral (ARV) history—including virologic responses, past ARV-associated toxicities, and cumulative resistance test results—is warranted before any treatment switch.1 Depending on the switch regimen being considered, patients may need to be virologically suppressed (<50 copies/mL) for a specified period of time (eg, 6 months); check prescribing information.2 The DHHS guidelines also cite simplifying a regimen by reducing pill burden and/or dosing frequency as a reason to consider regimen switching in the setting of viral suppression.
For patients with history of poor adherence to non-ARV medications, DHHS guidelines suggest considering regimens with a boosted PI or DTG, since these regimens have a high genetic barrier to resistance. If considering regimens with ABC, HLA-B*5701 testing should be performed before initiating therapy.
While BIC also has a high barrier to resistance, the guidelines note that there is currently no data on its efficacy in this population. NNRTIs do not have a high genetic barrier to resistance.
ABC=abacavir; ARV=antiretroviral; BIC=bictegravir; DTG=dolutegravir; NNRTI=non-nucleoside reverse transcriptase inhibitor; PI=protease inhibitor
http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed November 8, 2018.