Sequencing Therapy in HIV


Considerations for switching therapies used to manage patients with HIV following resistance or progression on prior treatment.

Grace McComsey, MD, FIDSA: John, as an HIV [human immunodeficiency virus] physician—you mentioned the study that will switch to darunavir COBI [darunavir-cobicistat-emtricitabine-tenofovir alafenamide]—if that is successful in alleviating weight gain, would you be in the same boat? Or would you say no, let me switch since I have other options, and not have to deal as much with the weight gain?

John Koethe, MD: With the shift in the HIV epidemic to a lot of long-term management, we’re all undergoing a career change and becoming a lot more adept at managing various comorbidities, knowing when to refer, and knowing what we can handle. Nutrition and weight management is something that we’re also having to learn on the fly. Some of our clinics are now integrating full-time nutritionists that we can send our patients to and we’re integrating body composition analysis too, to get a sense of, when somebody with a higher BMI [body mass index], when it’s predominantly fat mass vs something else. We’re doing a lot more in terms of metabolic monitoring. So there’s a balance between the 2. We’re getting a lot better at bringing up this issue of weight gain with our patients. We’re doing a better job of monitoring for cardiometabolic disease risk factors. But any retroviral agents are potent drugs, and although the field can breathe a sigh of relief with the quality of the drugs that we now have in terms of viral suppression, we still do see a lot of off-target effects from ART [antiretroviral therapy] agents. What we have now is by no means nontoxic, and Todd brought up the issue of the older thymidine analogues, like D4T [stavudine] and AZT [zidovudine], causing peripheral fat wasting. But Grace and Todd, from your own A5260s study, we know that, even on modern drugs, we still see a redistribution of fat to the viscera and to areas where it’s probably metabolically detrimental.

There’s probably going to be a role for both. There’s probably a group of patients who do have some increased weight that may be due to their medications. Although we don’t know if these trials of a switch are going to lead to weight gain and be successful, we also won’t know until we have real-world experience whether switching patients are going to show us the same result as we saw in a clinical trial setting. It’s definitely going to be 1 part of the armamentarium going forward.

Grace McComsey, MD, FIDSA: All of us have changed careers. Somebody approached me about doing a talk and she said, “I know you’re an endocrinologist. I want to bring Todd Brown because he will give the ID [infectious diseases] perspective.” And I just busted laughing. I said, “You mean the other way around?” She was convinced that I was an endocrinologist. And you’re ID, Todd.

Todd Brown, MD, PhD: That’s right.

Grace McComsey, MD, FIDSA: The 2 fields are coming together.

Todd Brown, MD, PhD: I’m happy to wear that badge.

Grace McComsey, MD, FIDSA: Thank you for watching this Contagion® Peer Exchange. If you enjoyed the content, please subscribe to the e-newsletter so you can receive upcoming Peer Exchange segments and other great content. Thank you for listening.

Transcript Edited for Clarity

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