HIV Treatment: Initiation, Adherence, and Accessibility
Segment Description: Joseph Eron, MD; Paul Sax, MD; W. David Hardy, MD; Eric S. Daar, MD; Ian Frank, MD, partake in a conversation on the importance of rapid treatment initiation, the difficulties of adherence, and accessibility.
Joseph Eron, MD: So I’m going to move to talking about treatment. And I just want to bookmark that, we’ll talk about U=U sometime during this treatment thing. Because I think it makes sense to now kind of talk a little bit more about the treatment landscape. Maybe, Eric, you could, like, set the picture. And then we’ll go through some more specific things. But maybe you could set up where we are.
Eric S. Daar, MD: Yeah. When I think about the treatment landscape, I still think it starts at the beginning, and it’s worth reminding everybody that after decades of debate as to when to start, I think everybody completely agrees that everybody diagnosed with HIV—regardless of their CD4 count, regardless of symptoms, regardless of comorbidities—should be offered and encouraged to initiate after antiviral therapy. And that’s because we now have convincing data showing that it prevents disease progression. In addition, we know, and we’ll talk about U=U, that it prevents transmission. But probably as important is that it’s just so darn easy to do. The treatment now, you know most people we start on 1 or 2 relatively small pills often in a day with virtually no adverse effects for the majority of them.
So the decision about when to start is very straightforward. Obviously we need to help people get prepared to take their meds consistently if they’re dealing with psychiatric disease and substance abuse and that. But so we should start everybody. And when we start the guidelines, there’s increasingly a consensus in the guidelines, both in the United States and in Europe, that most recommended regimens are 2 nucleosides and a third drug, and the third drug is essentially always an integrase inhibitor.
And the most recent guidelines, and we may go over this in more detail, have really focused on 2 of the more recently approved integrase inhibitors that are small pills and don’t require boosting, so you don’t have to worry about drug-drug interactions. They are generally very well tolerated and happen to have a high barrier to resistance. So even if things don’t go right, resistance is very unlikely to occur.
W. David Hardy, MD: And in many ways, as the guidelines become more and more small in terms of the number of recommended regimens, it’s getting easier for people who, unlike us, may not have been doing this all their lives and have always been put off by it. Because the guidelines used to have so many different options that it looked too confusing, and the guidelines were so expansive. You know, in younger providers now who are thinking about getting into HIV, the treatment has become simpler. And I think it’s all become good. The downside on all those regimens is really pretty small.
Joseph Eron, MD: That’s true. And 1 thing about treatment initiation is, how quickly should we do it? We’ve talked about this. It’s a thing.
Paul Sax, MD: It’s a thing, right. Historically there was this whole idea that before people started on ART [antiretroviral therapy], they needed to like go through a little educational course, an HIV 101 course, to learn about the importance of adherence and what viral loads CD4 mean and all this stuff. But it turns out that was all garbage. You know?
Eric S. Daar, MD: It wasn’t at the time.
Ian Frank, MD: There was a little garbage.
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