Difficult Cases of Antiretroviral Therapy by Dr. Michael S. Saag
Dr. Michael S. Saag, an expert in HIV/AIDS treatment, discusses challenging cases and treatment strategies in antiretroviral therapy. The presentation includes insights on managing mutations, selecting initial regimens, and adjusting therapy for long-term HIV patients. The cases highlight clinical considerations and decision-making processes in HIV care.
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Difficult Cases of Antiretroviral Therapy Michael S. Saag, MD Professor of Medicine Associate Dean for Global Health University of Alabama at Birmingham Birmingham, Alabama AU Final: 03/03/17 ZOOM: 11 August 2020
Financial Relationships With Commercial Entities Dr Saag has received research grants and support awarded to his institution from Gilead Sciences and ViiV Healthcare. (Updated 08/11/2020) Slide 2 of 51
Question What regimen should be used as initial therapy when an M184V mutation is present? Slide 3 of 51
Case 1 30 yo Female presents with newly diagnosed HIV infection Asymptomatic Initial: HIV RNA 28,000 c/ml CD4 count 650 cells/ul Other labs are normal; HLA-B57 neg Genotype shows M184V mutation No prior medical history. No children. Does not plan to become pregnant. Ok to start therapy if you think she should Slide 4 of 51
At this point which regimen would you choose? 1. TDF / 3TC / low dose (400mg) EFV (fdc; generic) 2. ABC/ 3TC / DTG (fdc) 3. TAF/ FTC (fdc) + DTG 4. TAF / FTC/ ELV / cobi (fdc) 5. TAF/ FTC / BIC (fdc) 6. 3TC/DTG (fdc) 7. TAF / FTC / RPV (fdc) 8. TAF/ FTC (fdc) + DRV/r (or cobi / fdc) 9. Some other option (e.g., DRV/r + DTG or ) Slide 5 of 50
Question Should I switch from EFV / FTC / TDF (fdc) in a patient who has been on it for the last 10 years? Slide 6 of 51
Case 2 45 yo Female referred to you for evaluation Diagnosed 13 years ago with HIV infection Initial: HIV RNA 36,000c/ml CD4 count 150 cells/ul Current: HIV RNA <20 c/ml CD4 count 525 cells/ul Started on EFV/ FTC/ TDF (fdc) in Jan 2007. Only regimen. Reports no symptoms currently. Generally feels well Slide 7 of 51
At this point you would: 1. Continue her current Antiretroviral Rx 2. Change her ARV Rx to 2 nucs and RPV 3. Change her ARV Rx to 2 nucs and a boosted PI 4. Change her ARV Rx to 2 nucs and an STII (integrase inhibitor) 5. Something else Slide 8 of 51
Question What do I do with a patient who has a discordant CD4 count response? Slide 9 of 51
Case 3 30 yo Female started on TDF / FTC /DRV / cobi 3 years ago Initial: HIV RNA 78,000 c/ml CD4 count 80 cells/ul Now: HIV RNA < 50 c/ml (persistently) CD4 167 cells/ul She is tolerating the regimen well Slide 10 of 51
At this point which regimen would you choose? 1. Continue her current Antiretroviral Rx 2. Change her ARV Rx to 2 nucs and an NNRTI 3. Change her ARV Rx to 2 nucs and a different boosted PI 4. Change her ARV Rx to 2 nucs and an STII (integrase inhibitor) 5. Change her ARV Rx to an STII and a different boosted PI 6. Something else Slide 11 of 51
What is Immunologic Failure ? 300 - 200 - 100 - 0 6 weeks 3 months 2 years 3 years - 1.0 - - 2.0 - - 3.0 -
Question How can I simplify a complex regimen in a highly treatment- experienced patient? Slide 13 of 51
Case 4 Case 4 57 year old man diagnosed with HIV in 1991; multiple opportunistic infections and complains of Pill Fatigue Has taken most existing antiretroviral drugs available; no exposure to maraviroc, DTG, or ELV Currently on TDF / FTC / ETV / DRV-r / RAL (1st InSTI) CD4+ count 330 / uL (nadir CD4 = 6) HIV RNA <40 c/mL (max VL 667,000) Slide 14 of 51
At this point which regimen would you choose? 1. Continue current therapy (9 pills) OR switch to: 1. TAF / FTC/ ELV / c (fdc) /DRV/c (2 pills) 2. ABC/ 3TC / DTG (fdc) / DRV/c (2 pills) 3. TAF / FTC / BIC / DRV/c (2 pills) 4. TAF / FTC / BIC / FOS (2 pills AM, one pill PM) 5. TAF / FTC / BIC / Ibilazumab (1 pill daily and an infusion every w weeks) 6. Some other regimen Slide 16 of 51
