HIV Treatment Initiation and Resistance Testing

Peter L. Salgo, MD: Individualizing care, individualizing any patient’s regimen, starts with what? How do you identify who needs this? How do you identify how urgent this is? Is it the HIV RNA level, the CD4 count, or what? How do you go about starting?

Michael Sension, MD: I think it’s my job as a clinician, as a doctor, to look at the patient, to look at their entire medical history. Do they have comorbidities? Are they going to be taking other medications that may have some side effects and/or drug-drug interactions with the potential HIV medicines that I’m going to choose? How likely are they to take their medicine? And we, physicians as a whole, are not always the best at predicting that, but we still have to do that.

Peter L. Salgo, MD: We’re not even the best at doing that. There’s that famous study where they gave a cohort of medical students one placebo per day and said, “Just take it for a year.” At the end of the year, they counted the number of pills that weren’t taken. It was about a third. So, we’re not very good at predicting adherence, are we?

Jeffrey Dunn, PharmD: No.

Michael Sension, MD: But we still have to do that, and there are some signs or some suggestions that somebody may have some issues.

Jeffrey Dunn, PharmD: Sorry to interrupt. I was going to say there are a lot of people working on more of the prospective analytics and patient segmentation. A lot of this is because we have better IT and we have better outreach programs to patients. So, I think we are trying to look at that a little bit differently, trying to figure out what’s going on with that patient and what type of patient they are, so that we can frame our interactions with them so it’s more effective. One patient may prefer a person-to-person meeting, another may prefer a text. Just understanding how they’re going to respond to things I think is huge.

Peter L. Salgo, MD: Do you need to identify the virus de novo, in terms of its resistance or nonresistance? Do some people get infected right away with a resistant virus?

Michael Sension, MD: It can happen, and it’s still important to do, if you will, a fingerprint or a resistance test on all people coming into care. The question is, do you need to wait until you get the result before you start people on medicine? The trend now is moving towards testing and treating immediately, immediately starting somebody on treatment because of the concern that if you wait—if you have them come back in a month to go over the results of their baseline testing—there is always going to be a certain number of people who don’t show up, who you lose to follow-up.

Peter L. Salgo, MD: A month, is that the turnaround on these tests? Is it a month?

Michael Sension, MD: It depends on which program you work in, but sometimes it can be 2 to 4 weeks to get back in turnaround time. But even if you say it’s 2 weeks, you still run the risk of losing people, of somebody not following up or coming back, and losing them to care. If the idea at the end of the day is to get as many people on a drug and completely virologically suppressed so that we reduce transmission, recent data suggest if we test and treat immediately, we’re more successful at getting more people to that goal.

Peter L. Salgo, MD: If you were to test and treat immediately, and you wanted to be sure you covered the waterfront, you would treat everybody with a drug that was least likely to induce viral resistance and then go backward from there and downregulate those people who have a virus that’s not subject to that. But that’s not what happens, I’m guessing.

Michael Sension, MD: Actually, if you look at the recommended regimens for test-and-treat protocols, they, for the most part, encompass that.

Peter L. Salgo, MD: Really?

Michael Sension, MD: Yes.

Peter L. Salgo, MD: There’s common sense out there?

Michael Sension, MD: There is common sense. I’ve actually been asked by the state of Florida, when we designed our protocols for test and treat, to weigh in on that and say what regimens we think would be most likely to cover the rare case of transmitted resistance virus or, on the flipside, to be more resilient to the development of resistance should somebody be prone to miss doses in the very beginning.

Peter L. Salgo, MD: Does that make sense to you? They’re going to give a more expensive drug. I’m assuming that’s more expensive.

Elly Fatehi, PharmD, BCPS: I don’t know what the cost of that product or that regimen is, but I’m assuming you’re talking about darunavir.

Michael Sension, MD: Darunavir and dolutegravir were the 2 main choices that we have gone with.

Elly Fatehi, PharmD, BCPS: From our perspective, because we want to end the epidemic and we want individuals to be virally suppressed, if there’s a drug that has a high barrier to resistance and if you miss 1 or 2 doses here or there, which I’m not advocating at all…

Peter L. Salgo, MD: Duly noted.

Elly Fatehi, PharmD, BCPS: It won’t affect any resistance issues, and we would be supportive of that.

Peter L. Salgo, MD: Does that make sense to you?

Jeffrey Dunn, PharmD: I would agree with that. We’ll be supportive of that. There are still other reasons for somebody not being adherent. I don’t want to look at this as a Band-Aid, but I agree. You want to start with the drug that has the best profile, but you still have to do other things to help these patients along.

Peter L. Salgo, MD: So, you start with the big gun and move back if you can. Is that fair?

Elly Fatehi, PharmD, BCPS: I don’t think you necessarily move back. I think you keep that big gun in place if that regimen is working.

Peter L. Salgo, MD: Are those the new guidelines?

Jeffrey Dunn, PharmD: Yes.

Michael Sension, MD: We don’t change. I agree.

Elly Fatehi, PharmD, BCPS: It’s not like antibiotic resistance or anything like that.

Michael Sension, MD: I think that with the recommended regimens we’ve just reviewed, recommended for most patients and recommended in specific or certain scenarios, once somebody starts on those regimens and is successful, we leave them on it. There’s no compelling reason to switch them off.

Peter L. Salgo, MD: But is that keeping up with the latest guidelines? Because my sense of the guidelines is that the people who get the powerful anti-resistance drugs are the carve-outs. They’re not the run-of-the-mill patient. Am I wrong about that? What am I missing?

Elly Fatehi, PharmD, BCPS: The one product that you mentioned was dolutegravir. That is an integrase inhibitor, so that’s actually in the guideline as a first-line treatment. The second product you mentioned was darunavir, which would be in the other, or the certain population category. So, I think what you’re talking about is actually in the guidelines.