Treatment Selection Challenges in HIV Infection

Joseph Eron, MD: Eric, what’s going to come off of the recommended guidelines? What would you take off that list, of 4 or 5 different regimens?

Eric Daar, MD: It’s always been a challenge for the guidelines panels. Do you really want to focus on the ones you actually use or the ones that are all reasonable options? Right now, there are not a lot of people, in a world of single tablet regimens, using a regimen that requires 3 pills a day, even once a day, like with raltegravir. I think raltegravir has stayed on because it’s probably the cleanest drug we’ve ever used, practically, with regard to side effects and drug—drug interactions. Clearly, it’s highly efficacious in every comparison, including against dolutegravir and boosted protease inhibitors [PIs]. It’s clearly a great regimen. I think it falls off on convenience. At some point, you just have to say, “It’s a perfectly reasonable option. But based on convenience, are there any reasons you would use it over the others?” And that becomes a discretionary point, as to whether people want to leave it as a preferred option or not.

Joseph Eron, MD: Colleen, is there any reason to keep something that has a booster in it now that we have bictegravir?

Colleen Kelley, MD: I think that’s a really good point. It sounds like probably not. I haven’t seen the size of the Biktarvy pill, but some of the newer integrase inhibitors and TAF [tenofovir alafenamide]—based regimens are incredibly small. Patients really appreciate not having to take the big horse pills any more. So, I offer them the choice. “Do you want 1 big pill or 2 little ones?” Very often, they’ll pick the 2 little ones. I think it is very exciting to have a small single-tablet regimen.

Joseph Eron, MD: It takes time for people to change. There are early adopters and later adopters. The other day, at the airport, I saw a guy use his Apple watch to go through security. There was someone right behind him with a piece of paper.

Eric Daar, MD: The big advantage of elvitegravir/cobicistat was that it was the single tablet regimen with tenofovir/FTC [emtricitabine]. And now there’s something else.

Joseph Eron, MD: Now we know that we have an alternative. To your point about dolutegravir, we certainly have more clinical experience with dolutegravir than we have with bictegravir. Some people might be early adopters. Other people might want to see more clinical data. That seems quite reasonable. We do have to see the longer-term tolerability with bictegravir. But the studies look very good, as Eric pointed out.

Colleen Kelley, MD: And of course, there are those patients who say, “If it ain’t broke, don’t fix it. I’m sticking with my regimen.” We have a lot of people on the boosted therapy, right now. They’ll be on it for a long time, I think.

Daniel Kuritzkes, MD: I think that’s a really important point. Every time you talk to a community-based group, and you talk about the current preferred options, everybody’s hands go up. “But I’m on darunavir/ritonavir. Should I change?” It’s like, “Absolutely not.” You should only change if you want to; not just because the guidelines have evolved. The guidelines have evolved in focusing on first-line therapy.

Joseph Eron, MD: Maybe there are primary care practitioners out there who share care with an expert. Certainly, when there’s something new that comes along, the patient is probably willing to get a tune-up, whether that tune-up is by phone or by sending them off to the expert to see whether their regimen can be tuned. Maybe some of those people on ritonavir have lipid abnormalities when they could be tuned up a little bit, too?

Eric Daar, MD: “I want to be on a single-tablet regimen.” That’s reasonable.

Joseph Eron, MD: But what we’re talking about doesn’t fit for everybody, Dan. So, what about regimens that kind of fall outside of the “for most patients” group?

Daniel Kuritzkes, MD: I think that there are fewer and fewer of those situations. But, for example, Eric brought up the question of the person in whom you have a concern about adherence. I’m not sure if there’s a lot of hard data around it, but there’s been a tradition for considering the use of a boosted protease inhibitor as first-line therapy when you’re not certain as to how reliably someone will take a medication.

That generally means more pills, though. Maybe the potential benefits or risk of resistance are counterbalanced by the greater complexity of the regimen? That’s never actually been studied. But a lot of clinicians, those who treat a large number of HIV patients, still feel that a boosted PI is something they can rely on if there’s somebody in whom they are particularly worried about adherence with.

Another situation that could be an issue is somebody who has advanced renal failure. The creatinine clearance is less than 30, and you really can’t use the newer formulations of tenofovir. They also have a risk for cardiovascular disease, which almost everybody with advanced renal disease has. Then, you wouldn’t want to use abacavir, either. And so, you may look at a more unusual regimen. In those situations, clinicians who are not doing HIV care as their main job should really refer to an expert because it gets very tricky after that.

Transcript edited for clarity.