The Evolution of Antiretroviral Therapy for HIV - Episode 6
When Comorbidities Influence HIV Management
Transcript (slightly modified for clarity)
Peter L. Salgo, MD: You mentioned hepatitis B and hepatitis C. How do you approach that? Is it a distinct subgroup of people who are HIV-positive?
Ian Frank, MD: Well, a lot of people with HIV also have hepatitis B or C co-infection.
Peter L. Salgo, MD: Right.
Ian Frank, MD: The drug that we would prefer to use in individuals with hepatitis B is tenofovir. Tenofovir not only treats HIV, but it also treats hepatitis B. The TAF (tenofovir alafenamide) formulation has recently been FDA-approved to treat hepatitis B as well. So for those individuals with hepatitis B, we definitely want to give them a tenofovir-inclusive regimen. Usually we’re, as Eric said, thinking about a nucleoside combination, which is either going to be TAF/FTC (tenofovir alafenamide with emtricitabine) or abacavir/lamivudine. That’s going to be the nucleoside component. So, if somebody’s got hepatitis B co-infection, we’re going to give them a tenofovir-inclusive regimen.
Peter L. Salgo, MD: Okay. Now what about hepatitis C?
Ian Frank, MD: In hepatitis C, again, the great thing about the integrase inhibitors is they don’t have a lot of drug—drug interactions.
Eric S. Daar, MD: At least 2 of the 3.
Ian Frank, MD: Yes. So we can use dolutegravir or raltegravir. We could use abacavir/lamivudine. There’s few drug—drug interactions with the TAF formulation. So, for the most part, these same regimens are pretty safe and effective. Occasionally, there’s a drug–drug interaction that an astute HIV hepatitis C provider will be aware of. But for the most part, hepatitis C doesn’t influence our treatment decision.
Peter L. Salgo, MD: What about comorbidities (ie, patients with bone disease, kidney disease)?
Joseph Eron, MD: That’s where it gets a little sticky. You get people that are newly diagnosed, but they’re older. They have diabetes, perhaps, or they have renal dysfunction. Then you really have to be careful and that definitely influences your choices. You have women that have multiple pregnancies and may be really at risk for osteoporosis. We know that tenofovir, especially the TDF form (tenofovir disoproxil fumarate), lowers bone density, but the TAF form appears not to do that. So, you want to think very carefully about the comorbidities. There is the drug—drug interaction issue, and in people that are on some of the more complicated diabetes regimens, maybe there are things you need to consider. But, in general, again, as Ian said about hepatitis C, what we’re choosing now is really so tolerable and the interactions are few. Unless you have really frank renal failure—then you’re kind of a little bit more stuck.
Paul E. Sax, MD: We face the issue with comorbidities, more commonly, in the people who have been on therapy for years, rather than in newly diagnosed patients. All of us have this panel of patients, now, who are aging with us. They’ve been on HIV treatment, sometimes very toxic HIV treatments for 5, 10, 15 years. And so they’re the ones we sort of struggle with in terms of the comorbidities—more than the newly diagnosed patients. One of the companies tried to do a study of people with newly diagnosed HIV in renal disease, and it’s actually very hard to do because there aren’t that many people who have renal disease.
Joseph Eron, MD: We talk about it a lot, but it’s not that common.