Academy Exchange

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

Hi Stephen,

Why would you be leary of using lenacapavir?    You are worried about a lower barrier to resistance and him missing every six month doses?    But, I personally worry more about the increased pill burden of fostemsavir, since it is a BID drug.    Anyway, many ways to go here.

------------------------------
Adam Zweig
AIDS Healthcare Foundation
San Diego CA

Original Message:
Sent: 08-06-2023 14:42
From: Stephen Adams
Subject: K65R + M184V with possible pan insti resistance

You could use fostemsavir instead of the DOR. With his noncompliance history I'd be very Leary of using Lenacaprivir.

Sent from my iPad
Stephen R Adams, MD


Original Message:
Sent: 8/4/2023 12:41:00 PM
From: Ashwin Gupta
Subject: K65R + M184V with possible pan insti resistance

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

------------------------------
Ashwin Gupta
Philadelphia PA
------------------------------

Hi Adam (and Stephen, James, Jacob, Alexander) and every one else. Sorry for such a late reply;

I have some updates
(1) phenosense with trofile is pending
(2) for the case discussion -- I was able to review chart data and past genos from a previous ID provider outside of my current health system----  he has/had DOR resistance and RPV resistance in the past! womp wompp
(3) I was very interested in everyone's thoughts about DOR vs RPV; which NNRTI would be people's preference in a setting of non-NNRTI resistance. Seems there's agreement that DOR may be more preferable to RPV

In this case, I was left with DRV/c/T/F + fostemsavir: 3 total pills a day (1 qD and 1BID). I agree this increases the bill burden and dietary needs, not amazing.
I am hopeful this will be the consistent and best regimen for this person.

------------------------------
Ashwin Gupta
Philadelphia PA

Original Message:
Sent: 08-07-2023 11:42
From: Adam Zweig
Subject: K65R + M184V with possible pan insti resistance

Hi Stephen,

Why would you be leary of using lenacapavir?    You are worried about a lower barrier to resistance and him missing every six month doses?    But, I personally worry more about the increased pill burden of fostemsavir, since it is a BID drug.    Anyway, many ways to go here.

------------------------------
Adam Zweig
AIDS Healthcare Foundation
San Diego CA

Original Message:
Sent: 08-06-2023 14:42
From: Stephen Adams
Subject: K65R + M184V with possible pan insti resistance

You could use fostemsavir instead of the DOR. With his noncompliance history I'd be very Leary of using Lenacaprivir.

Sent from my iPad
Stephen R Adams, MD


Original Message:
Sent: 8/4/2023 12:41:00 PM
From: Ashwin Gupta
Subject: K65R + M184V with possible pan insti resistance

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

------------------------------
Ashwin Gupta
Philadelphia PA
------------------------------

Hi Adam (and Stephen, James, Jacob, Alexander) and every one else. Sorry for such a late reply;

I have some updates
(1) phenosense with trofile is pending
(2) for the case discussion -- I was able to review chart data and past genos from a previous ID provider outside of my current health system----  he has/had DOR resistance and RPV resistance in the past! womp wompp
(3) I was very interested in everyone's thoughts about DOR vs RPV; which NNRTI would be people's preference in a setting of non-NNRTI resistance. Seems there's agreement that DOR may be more preferable to RPV

In this case, I was left with DRV/c/T/F + fostemsavir: 3 total pills a day (1 qD and 1BID). I agree this increases the bill burden and dietary needs, not amazing.
I am hopeful this will be the consistent and best regimen for this person.

------------------------------
Ashwin Gupta
Philadelphia PA

Original Message:
Sent: 08-07-2023 11:42
From: Adam Zweig
Subject: K65R + M184V with possible pan insti resistance

Hi Stephen,

Why would you be leary of using lenacapavir?    You are worried about a lower barrier to resistance and him missing every six month doses?    But, I personally worry more about the increased pill burden of fostemsavir, since it is a BID drug.    Anyway, many ways to go here.

------------------------------
Adam Zweig
AIDS Healthcare Foundation
San Diego CA

Original Message:
Sent: 08-06-2023 14:42
From: Stephen Adams
Subject: K65R + M184V with possible pan insti resistance

You could use fostemsavir instead of the DOR. With his noncompliance history I'd be very Leary of using Lenacaprivir.

Sent from my iPad
Stephen R Adams, MD


Original Message:
Sent: 8/4/2023 12:41:00 PM
From: Ashwin Gupta
Subject: K65R + M184V with possible pan insti resistance

Hi all,

Just a bit curious what others would do in this situation:

44yo male, MSM.
Newer patient to practice from an mpx diagnosis through ED in 12/22; subsequently new linkage to care with our team for HIV starting in March after LTFU s/p completion of TPOXX. Pt states off ART completely for 5+ months. Genotyping conducted on that first linked-to-care HIV appt showing pan-susceptibility, VL 1740 . Pt states hx of several various HIV offices in the surrounding area since 2013 dx along with many ART combinations (some previous ART: epizom, DTG+Tdf/F, RTV+TDF, DRV/c+doravirine). Patient rescreened at next appointment in May 2023, VL of 299 with BIC/T/F. 1 week later, enrolled in a research study and re-screened; genotyping showing pan insti resistance, K65R and M184V. VL 12,300.

Patient asked about medication adherence, stating daily only 1 missed dose over the last 1-2 months. 

At this point, we have pan-PI and pan NNRTI susceptibility. 
Engaging with patient, explained he will need to be prepared for a switch off STR, and will likely need two tablets per day. 
Newest VL now 30,400.... don't yell at me, I collected a phenosense in anticipation of a VL increase. 

I will have to take him off BIC/T/F obviously, but what kind of regimens are people using with K65R+M184V (and Y115F but I wasn't considering ABC for the future, anyway). The geno is predicting pan INSTI resistance (Q148R, E138K).

I'm leaning towards DRV/Cobi/T/F + DOR

Any thoughts or advice appreciated!

-A

------------------------------
Ashwin Gupta
Philadelphia PA
------------------------------