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    Posted 02-06-2024 16:58

    Good day,

    I need some guidance about a 48 year old man with HIV infection since 2002.  His initial regimens included efavirenz (apparently failed this, but no records to review), NVP (hypersensitivity reaction).  He then was switched to FTC-TDF, MVC, RAL for awhile and is now on DRV/r, DTG (twice daily), AZT-3TC.  I don't have any records.  

    He has chronic pain stemming from low back issues for which he has been on opioids for years.  Despite telling me that he is taking his medications, his VL remains elevated in the 400K range.  All genotypes show wild type virus, and ARCHIVE genotyping shows no evidence of resistance. An endoscopy was done for work-up of vomiting which showed opioid associated esophageal outlet obstruction. CD4 count <200

    The issue is switching to an injectable regimen, but what do you make of possible failure to EFV and hypersensitivity to NVP, and can I trust that he does not have resistance to INSTIs?  I'm working on tapering his off opiates, but that will take some time.

    Thanks in advance,


    Emanuel Vergis
    San Rafael CA


    Posted 02-06-2024 21:23

    It seems obvious that your patient is not taking anything; but on the other side we have to consider that is on a very high pill burden and a complicated treatment.

     I would analyze the situation like this:  
    1- Is over medicated 

    2- He can have resistance to NTRI and NNTRI (or at least we have to think he has) even is not visible on genotypes I would take that as a fact.

    3- Has he developed resistance to INSTI ? - We don't know that is something that depends on the way he took RAL and DTG probably no but starting BIC or DTG  is something that will leave us a little worried. 
    4- CABO RIL? After long time on EFV and the doubt a lot INSTI resistance will make me worried too and if he gets lost to follow up certainly will be in a bigger problem.

    what would I do? 
    I would with the patient and make a short time compromise with a simple treatment he can take once a day and a single dose recycling NITR.


    1- Biktarvy (no evidence published in this particular scenarios but of you want to go with INSTI that will be my choice.

    2- TXF/FTC DRV800 boosted with either RTV or CABO 

    60 days  compromise (Less if you take option 1 and take 
    viral load and continue evaluating frequently. 

    Why my choice would be number 2? because it has published evidence (recycling NITR) meanwhile evidence on BIC in this context has not yet broadly published.

    Ok let's talk about this interesting case ! 

    William Lenis
    Fundacion Valle del Lili


    Posted 02-07-2024 19:43
    I completely agree with the response and obviously any resistance will be attributible to how "compliant he was in the past"!!

    Bill Robbins


    Posted 02-07-2024 17:02

    Hi Dr Vergis,

    How have you been?

    So, this guy is not taking his meds.  None of his resistance meds have ever shown RAMs, correct?  I imagine it is because of the GI issues.  If that is true, then the only option for this guy is to go on injectables.  Obviously, this would be off label for Cabenuva, but I think his situation forces your hand.    I would likely add Sunlenca to improve the potency of the regimen and increase the chance of obtaining viral suppression.  You could even add Trogarzo, but then you are adding complexity and cost.    So, for me, I would do Cabenuva/Sunlenca.   Maybe drop the Sunlenca when and if he becomes suppressed.   I don't think he has many options otherwise.  Interested in other ideas.

    Adam Zweig
    AIDS Healthcare Foundation
    San Diego CA