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International ART availability

  • 1.  International ART availability

    Posted 05-21-2020 15:18
    Hi all,

    I have a new patient coming to me on EFV and ABC/3TC. Obviously want to get him off EFV. No resistance mutations, always suppressed, only one regimen, renal function good, no Hep B. No other comorbidities or medications. So we have many options for switching.

    His partner is a diplomat for another country (not the US) and they move around the world. He's reluctant to change regimens because he's concerned about having access to newer ART.

    Here's my question: Are there single pill regimens (BIC/TAF/FTC, DTG/ABC/3TC, etc.) that are widely available around the world? Or is there a site/reference you can point me to for this information?

    Want to avoid putting him on a regimen he won't be able to continue in another country if possible.

    Thanks!
    Paul

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    Paul Sacamano
    El Rio Health
    Tucson AZ
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  • 2.  RE: International ART availability

    Posted 05-22-2020 15:47

    Hi Paul,

    Coincidently I had the same question this morning regarding a specific product. 


    If they travel/live in US, Canada, or Western Europe most regimens would be available and so I wouldn't worry at all for drug selection purposes.


    if they go to any LMIC then it's a different story. The predominant STRs are TDF/3TC/DTG and EFV/TDF/3TC. Additionally individual components are available for those products. to my knowledge there are not any TAF or BIC regimens available in LMICs.


    there's no renal issue? Just surprises me that he's on ABC instead of a tenofovir product.

    An easy bet would be to use a DTG based regimen - with 3TC as a STR or combine with TDF/FTC or TAF/FTC. It won't be perfect but would allow for some easy conversion outside the US.

    Hope that helps!

    Katy






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    Katy Garrett
    Portland ME
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  • 3.  RE: International ART availability

    Posted 05-22-2020 16:33
    The availability of the newer ARTs will depend on the country. Do you know which country/countries they move to? Also a lot of health plans will allow patients to fill more than  30day supply of a medication when they travel; he can potentially get a 3-6 month supply of the new medication.

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    Elsa Tchakoute, PharmD, AAHIVP
    Phoenix, AZ
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  • 4.  RE: International ART availability

    Posted 05-22-2020 18:30
    Paul, 
    I believe that you are correct in recommending that he change his EFV + ABC/3TC regimen to an InSTI-based regimen.
    In my experience, ARV availability outside the US can be highly variable and dependent on insurance type even in countries with national healthcare systems. Having international private insurance makes a big difference to go beyond often-limited national drug formularies. 
    Drug approvals often vary country by country depending on whether the pharmaceutical manufacturer wants to create a market in the country or if a generic company has manufactured US-based patented drugs via the international patent pool. 
    A potentially good resource for obtaining ARV availability outside the U.S is Tim Horn (THorn@NASTAD.org) at NASTAD. Tim is a wizard on drug pricing in the U.S. healthcare system and if he can figure this out, international drug availability is a piece of cake.

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    W. David Hardy, MD
    Los Angeles CA
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  • 5.  RE: International ART availability

    Posted 05-22-2020 20:46
    I have started to become less aggressive about switches, honestly.  If patients want to take Efavirenz for whatever reason, then let them as long as they aren't having adverse reactions.  Sure, bringing them off of the Efavirenz might clear their head and they might find out that they are less depressed than when they were on it or whatever, but unless they're having high lipids or terrible dreams/depression, I'd just leave them on it.  Just my opinion.

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    James Adams
    Rancho Mirage CA
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  • 6.  RE: International ART availability

    Posted 05-23-2020 16:37
    I'm with you, James.  Many thousands of lives have been saved with EFV/TDF/FTC over the years.  When we started out, the trade-off between viral suppression and the hypothetical lipid/cardiac implications of EFV would have been laughable. Obviously, a change is needed if the patient has psychiatric symptoms or sleep disturbance.   I'm equally concerned about nephrotoxicity from TDF.  Over time, most of my EFV/TDF/FTC patients have transitioned to INSTI-based single pills, but I have several who are very comfortable on the old stuff, and if it ain't broke why fix it?

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    Sandra Wallace
    Nicasio CA
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  • 7.  RE: International ART availability

    Posted 05-24-2020 11:54
    Edited by James Adams 05-24-2020 11:55
    Exactly, Sandra, and I have encountered that lots of patients do not tolerate the switch very well and will want to go back on their last regimen.  For instance, I used to try to talk my Genvoya patients into switching to Biktarvy due to drug interactions and wanting to get them off of one more chemical (cobi)  but a lot of them want to switch back once they think they are feeling side effects from the Biktarvy. Weight gain is a common complaint after switching, so I then have to switch them back to Genvoya and maybe alter other med dosages in case they require them due to cobi boosting.  It's a lot of work for nothing in some cases.  I have thus taken a less aggressive stance to switching folks unless there is something glaringly wrong about their regimens that requires a switch.

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    James Adams
    Rancho Mirage CA
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  • 8.  RE: International ART availability

    Posted 05-26-2020 10:46
    Thanks to everyone for the feedback.
    Paul

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    Paul Sacamano, PhD, MPH, NP-C
    El Rio Health
    Tucson AZ
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