Joseph Eron, MD, Daniel R. Kuritzkes, MD, and Monica Gandhi, MD, MPH, examine the many factors associated with increased risk of HIV, including substance abuse, unstable housing/food situations, and mental illness.
Joseph Eron, MD: Monica, there are people at higher risk of becoming highly treatment experienced. The other way I think about it is that these are people with limited treatment options. Who are the people at greatest risk?
Monica Gandhi, MD, MPH: We have 2 populations. One population, from the beginning, has been on so many medications. They got diagnosed early in the epidemic, but these medications were hard to take. That led to thymidine analog mutations, and there’s an accumulative resistance over time. In terms of the other category, the people who can’t tolerate HIV medications, to me it’s not as much about tolerability—which has gotten much better with time—as it is the inability for other reasons to take daily oral regimens.
In San Francisco, it boils down to 3 major reasons. One is substance use, which intensified during the COVID-19 pandemic. The second is unstable situations in housing or food. The third thing we’re seeing is mental illness. Those 3 categories are the populations that are left to treat and that we call the final 10%. We’ve called them the goal of the HIV epidemic initiatives. That population tends to carry 90% of the virus, whether it’s tolerability or inability, 1 day or taking it every day. Can we think about regimens that are easier to take, that we can administer, that are taken much less often than daily? How do we get creative with that patient population? It’s getting rarer to have truly multidrug-resistant HIV.
Joseph Eron, MD: Yes, absolutely. I couldn’t agree more.
Transcript Edited for Clarity