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HIV Therapy Selection for the General Population

MAY 01, 2019 | PANELISTS:JOSEPH ERON, MD; PAUL SAX, MD; W. DAVID HARDY, MD; ERIC S. DAAR, MD; IAN FRANK, MD
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Segment Description: Key opinion leaders consider the best treatment options for the general HIV population.

Joseph Eron, MD: Let’s get back to kind of choosing a therapy. So all kinds of benefits getting people on rapidly, decreasing transmissions, making people less stigmatized and untransmissible, as David said. What about selecting therapy, Ian? What goes into your thinking about how to select therapy? Or is it now so easy, we don’t really have to think that much?

Ian Frank, MD: Well, I think there has been a convergence of therapies in a lot of ways, and we don’t really need to think quite as much. I’ll go through some of the factors we used to consider, and we’re going to talk about maybe some people who don’t fit into the general category, who are the exceptional patients where we really need to focus our thoughts a little bit harder. But we used to worry about CD4 count and viral load. I think it’s certainly true that even with the newest therapies, maybe people with CD4 counts that are on the lower side may not do as well as people with CD4 counts higher. But it’s difficult to distinguish between 1 combination and another, even in people whose CD4 counts are low and whose viral loads are high. When we’re choosing a next-generation integrase inhibitor, bictegravir or dolutegravir, and when we’re using the kind of active nucleoside combinations that we most commonly do, generally tenofovir alafenamide, maybe abacavir when needed in some situations.

We used to worry about cardiovascular disease. We don’t have to worry so much about that with the next-generation integrase inhibitors. We may not want to use abacavir or lamivudine. There may be a signal of an increased risk of MIs [myocardial infarctions] in people who are on abacavir regimens. We used to worry about tenofovir and renal effects and effects on bone density with tenofovir alafenamide. We probably don’t need to worry about that complication so much.

If individuals have chronic hepatitis C infection, you may want to have avoided an efavirenz-based combination or boosted protease inhibitor combination in the past because of drug-drug interactions with the directly acting anti–hepatitis C drugs. If you use an integrase inhibitor, you don’t have to worry about those interactions.

If somebody has chronic hepatitis B, you want to start them on a tenofovir-based regimen, so that’s a coinfection for which you want to make sure you choose a particular nuke combination. But we don’t have to worry about lipid effects so much. We don’t have to worry about other metabolic complications the way we used to. So I think it’s really become a lot simpler.

W. David Hardy, MD: You just made the case for why we can do rapid initiation.

Joseph Eron, MD: Yeah.

W. David Hardy, MD: Because all those labs that we used to have to draw and wait for to come back, we don’t really need to wait for them anymore, other than the positive HIV test, the confirmation test.

Ian Frank, MD: Pregnant women and women who are electing to become pregnant would probably be the largest group who would maybe fall outside the general guideline.
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Big advances in treatment can't make up for an inability to stop new infections, which number 5,000 per day worldwide.