Vera’s Chief Complaint & History of Present Illness
Vera, a 33-year-old, HIV-1-positive African American female,* reports depression, anxiety, insomnia, and weight gain of 10 pounds over the past year.
- HIV-1 diagnosis at age 30
Multi-tablet regimen prescribed at that time
Virologic failure ~1 year ago; switched to Triumeq® (DTG/ABC/3TC) at that time
Anxiety, depression, and trouble falling/staying asleep developed 10 months ago
- 9 months ago: Started on sertraline 50 mg daily for depression. Symptoms improved with treatment
*This is a hypothetical patient.
3TC = lamivudine; ABC = abacavir; DTG = dolutegravir
Triumeq is a registered trademark of ViiV Healthcare.
Vera’s Personal & Social History
Sexual history: Stable, heterosexual relationship
Occupation: Full-time hairdresser; busy working mom
Appreciates convenience of current STR
- Divorced, lives with her two young children
Long hours at salon
Juggling work and childcare often makes her feel stressed and overwhelmed
STR = single-tablet regimen
Vera’s Physical Exam & Lab Tests
- Physical exam: Normal
- Fasting glucose: 90 mg/dL
- Fasting lipids:
- TC: 165 mg/dL
- LDL-C: 75 mg/dL
- HDL-C: 70 mg/dL
- Trig: 100 mg/dL
- Serum creatinine: 0.89 mg/dL
- AST and ALT: WNL
- Pregnancy test: negative
- HIV panel
- HIV Genotypic Resistance: Results from ~1 year ago, after initial virologic failure on an MTR. M184V mutation reported
- Viral load: undetectable (<50 copies/mL) for 9 months
- CD4+ cell count: 520 cells/mm3
ALT = alanine aminotransferase; AST = aspartate aminotransferase; CD4+ = cluster of differentiation 4; MTR = multi-tablet regimen
33-year-old female with HIV-1 who is virologically suppressed on current therapy but experiencing tolerability issues:
Previous treatment failure with MTR; known resistance
Currently experiencing tolerability issues
Hectic lifestyle; stressed and overwhelmed balancing work/home demands
Appreciates convenience of STR
MTR = multi-tablet regimen; STR = single-tablet regimen
If you are considering switching Vera’s ARV regimen, what potential factor(s) may be relevant in your regimen recommendation?
- 9 months of virologic suppression (<50 copies/mL)
- Adherence to current regimen
- Co-morbid conditions (eg, depression)
- All of the above
In addition to patient counseling and a follow-up visit in 2-4 weeks, which of the following single-tablet regimens would you consider prescribing for Vera?
- Atripla® (EFV/FTC/TDF)
- Biktarvy® (BIC/FTC/TAF)
- Juluca® (DTG/RPV)
- SYMTUZA® (DRV/c/FTC/TAF)
All 3 factors may be relevant to your ARV recommendation.
- Some medications require that virologic suppression (<50 copies/mL) be established for a minimum amount of time (eg, 6 months).1
- DHHS guidelines state that STRs that include all antiretrovirals in one pill/daily are easier for people to use.2
- The guidelines state that comorbid conditions, including psychiatric disorders, may predispose individuals to adverse effects of certain ARV medications.2
http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed November 8, 2018.
DHHS guidelines state that review of cumulative resistance test results is essential when designing a new regimen. Cumulative resistance test results refer to all previous and currently available results from standard genotype, proviral DNA genotype, phenotype, and tropism assays that can be used to guide the selection of a new regimen.1 In addition, certain ARV medications should not be used by patients with a history of treatment failure.2,3 Check prescribing information for any switch regimen being considered.
The DHHS guidelines note that psychiatric disorders may be exacerbated by EFV, RPV and, infrequently, by INSTIs.
ARV=antiretroviral; EFV=efavirenz; INSTI= integrase strand transfer inhibitor; RPV=rilpivirine