Academy Exchange

I have a 49 yo male, heavily treatment experienced with HIV/HBV, CKD, and hypophosphatemia. Creatinine stable at 1.5 mg/dL, CrCl ~ 55 mL/min. 

He was previously on some pretty wonky regimens - failed RAL BID + ABC/3TC, was transitioned to ETR BID + DRV/c daily + AZT/3TC BID. Then TDF 300mg daily added to this regimen, discontinued due to renal decline and started on FTC/TAF (while continuing 3TC/AZT BID...). I was able to simplify his regimen to DRV/c + DOR + TAF and he has remained undetectable for the last 5 years.

HIV mutations are as follows:
PI - E35D, M46M/I
RT: V35D, M41L, K65R, V106V/I, M184V
INSTI: G140S, Q148H

HBV genotype includes L180M and M204V with 3TC/FTC resistance and entecavir resistance possible. He came to us on entecavir treatment and was never suppressed until transition to TAF. His HBV DNA PCR was 34,000 when he transitioned to TAF (down from >170,000,000 at treatment onset) and became suppressed over the next several months.

His phosphorus level was low (2.0 mg/dL) at routine annual check in Jan 2023 (down from 3 mg/dL Jan 2024). Repeated phos two weeks later was 1.8 mg/dL - calculated fractional excretion was 25.9%. At that time, we referred to nephrology and tried to find a suitable non-tenofovir based regimen to no avail. His phos stabilized for the remainder of 2023 but has dropped again - most recently down to 1.3 mg/dL while on K-Phos 500mg PO BID. 

I feel we need to discontinue tenofovir based regimen but the only other first-line option for HBV is pegylated interferon which he will likely not tolerate. I am also apprehensive to have him on dual HIV therapy given his extensive treatment history/failures and current mutations. I would be comfortable adding LEN on to DRV/c + DOR and maintaining suppression but really struggling to find a feasible HBV treatment with the rest of the clinical picture.

Any suggestions would be greatly appreciated!

I have a 49 yo male, heavily treatment experienced with HIV/HBV, CKD, and hypophosphatemia. Creatinine stable at 1.5 mg/dL, CrCl ~ 55 mL/min. 

He was previously on some pretty wonky regimens - failed RAL BID + ABC/3TC, was transitioned to ETR BID + DRV/c daily + AZT/3TC BID. Then TDF 300mg daily added to this regimen, discontinued due to renal decline and started on FTC/TAF (while continuing 3TC/AZT BID...). I was able to simplify his regimen to DRV/c + DOR + TAF and he has remained undetectable for the last 5 years.

HIV mutations are as follows:
PI - E35D, M46M/I
RT: V35D, M41L, K65R, V106V/I, M184V
INSTI: G140S, Q148H

HBV genotype includes L180M and M204V with 3TC/FTC resistance and entecavir resistance possible. He came to us on entecavir treatment and was never suppressed until transition to TAF. His HBV DNA PCR was 34,000 when he transitioned to TAF (down from >170,000,000 at treatment onset) and became suppressed over the next several months.

His phosphorus level was low (2.0 mg/dL) at routine annual check in Jan 2023 (down from 3 mg/dL Jan 2024). Repeated phos two weeks later was 1.8 mg/dL - calculated fractional excretion was 25.9%. At that time, we referred to nephrology and tried to find a suitable non-tenofovir based regimen to no avail. His phos stabilized for the remainder of 2023 but has dropped again - most recently down to 1.3 mg/dL while on K-Phos 500mg PO BID. 

I feel we need to discontinue tenofovir based regimen but the only other first-line option for HBV is pegylated interferon which he will likely not tolerate. I am also apprehensive to have him on dual HIV therapy given his extensive treatment history/failures and current mutations. I would be comfortable adding LEN on to DRV/c + DOR and maintaining suppression but really struggling to find a feasible HBV treatment with the rest of the clinical picture.

Any suggestions would be greatly appreciated!