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Heavily Treatment-Experienced Patients and Management of Multi-Drug Resistant HIV-1 Infections - Episode 6

Managing Patients With Suboptimal Treatment Response

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Joseph Eron, MD, Daniel R. Kuritzkes, MD, and Monica Gandhi, MD, MPH, review strategies for determining whether drug resistance is the primary reason for suboptimal treatment response or adherence.

Joseph Eron, MD: The next thing I'm going to do is start with you, Monica, and then go to Dan, kind of in 2 parts. The first part is someone who comes in, they're on therapy, you've prescribed it, and they're not virologically suppressed. The first step is, Monica, your approach to understanding that. Then I'm going to go to Dan to talk about what resistance tests you do, what you should, what kind of laboratory evaluation should you do? First, what kind of evaluation of the person do you do?

Monica Gandhi, MD, MPH: I always repeat it just in case there's a mix-up, but even the first day I do discuss it with the patient. Like you said, that can bring up anxiety but it's important to do that. Then it's really important to discuss the values and then ask about adherence. How often do you take it? I do it in packets of time. Is it every week, every month? What reminds you? Some people do it when they brush their teeth. Some people have it at their bedside table if there's not stigmatization. There's a lot of coffee that's brought up in the morning and they have the pills right there. What is your trigger to remind you? Partners remind people.

We talk through adherence and then we talk through tolerability. What am I missing? Maybe you're feeling side effects? Like you said, stigmatization is more of a...I was in India recently and stigmatization is a very big deal there. We should not underestimate how much stigma is still there for having an HIV medication out in the household, or roommates seeing the HIV medication. Where do you put it? Do you put it in your bag? Do you forget, if you're staying overnight somewhere else, to take it? We go through many questions, repeat the viral load, and then if it's still detectable then go for what Dan is going to say.

Joseph Eron, MD: I do think that there are other life chaos things that you have to talk about. A family member dying, etc. Unfortunately, I think women with living with HIV are frequently the caregivers for many other people. They may believe they're being very adherent, but when you get down to it sometimes, it's just there are just so many other things that are competing.

Monica Gandhi, MD, MPH: Competing priorities.

Joseph Eron, MD: Then you've mentioned kind of mental health issues. I've had patients where they go to the wrong street corner and they're back on methamphetamine even though they've been clean for quite a long time. Those are things that come up.

Dan, in the grand scheme of things, multidrug resistance and its problems now compared to the past. Where would you say we are?

Daniel R. Kuritzkes, MD: It's much less of a problem. I'd say the height of multidrug resistance really was at the end of the 1990s and the early 2000s and that's because we still had so many people who had started on AZT (zidovudine) monotherapy. They either added DDI (didanosine) when that came around or 3TC (lamivudine), so then they were on dual nucleoside therapy and became resistant to both drugs. Then when the protease inhibitors [PI] came out, they were adding what was essentially protease monotherapy to failed nucleoside therapy. Then they developed resistance to one protease inhibitor after another.

Fortunately, we're not in that circumstance any longer so people starting on treatment today, they almost all become suppressed, and because of the high barrier to resistance of the 8 drugs we're using, it's very rare for people to get resistant to all of the components of their regimen. Even if they got resistance to 3TC (lamivudine) or FTC (emtricitabine) or became resistant to tenofovir, they're not going to have, in most cases, resistance to either the integrase inhibitor or the boosted PI.

We're generating new multidrug resistance much less commonly, at least here in this country. Elsewhere there are issues especially because of problems with getting frequent viral load monitoring. If you look at the data—and just recently we were talking about these data that Ron M. Kagan had published, which take us up to 2017, which is already a little bit out of date—but they were seeing a steady decline in this large reference lab in the number of samples that they received that tested out for multidrug resistance.

Transcript Edited for Clarity