Choosing a Regimen to Treat HIV

Frank J. Palella, MD: There are a diverse array of factors to be seriously considered before initiating therapy for HIV. These are not only viral-related factors like the viral load, whether resistance or preexisting conditions are present, CD4s, whether the patient has been symptomatic from HIV or has had an opportunistic disease but also, and more importantly, what are the most effective options available and what sort of comorbidities does the patient have? We need to remember that among the 1.2 million or so persons with HIV in the US, about half are over the age of 50, and that is because we’ve managed to extend survival so remarkably.

But what that means is that when we prescribe a regimen for the treatment of HIV the likelihood of comorbidities being present requiring separate treatment will be high. We need to make sure that the therapies that we prescribe for HIV do not increase risks for aging-related, non-infectious comorbidities that we all are increasingly at risk for as we get older and also that the therapies do not adversely interact with the medications that these patients might also need, say for the treatment of hypertension, hyperlipidemia, depression, erectile dysfunction, and anxiety. So, comorbidities are a huge issue--both if they’re present and if the patient is at risk for them. We don’t want medication that treats HIV to contribute to other problems or cause other risks for good health.

We also know that resistance is important. In order for the therapies that we prescribe for HIV to work optimally, we need to know that we have as active an antiretroviral regimen as we can against that person’s viral isolates. We achieve this through doing and evaluating resistance tests. For a person who’s naïve to therapy, meaning it’s their first time ever, we do a single genotype in advance of starting therapy and use the results to guide us. In persons who are switching therapies, we try to assemble all of the historical resistance tests they ever had done.

For instance, if they’ve been on therapy for 10 years and during that period of time have had several resistance tests, we need to review the results from each of them because any resistance mutations or any indication of potential compromise in a drug’s activity that was ever present on any one of those tests has to be considered to continuously be present, even if it didn’t show up on the most recent assay. That’s why we talk about the cumulative evidence of resistance, a very important factor.

And lastly, adherence is also important. If a patient encounters challenges in taking medication, either through the number of pills, the size of pills, needing to dose around meals, or being negatively reinforced to take their pills because of side effects, those challenges will have to be taken very seriously. The medication can only be of value if it is optimally adhered to--if persons with HIV receiving these medications are capable, willing, and eager to take their medication as prescribed.

Transcript edited for clarity.