Academy Exchange

I took over the care for a very treatment experienced patient (HIV for 30+ years, multiple failures prior to INSTI) with a high burden of co-morbidities.

I really would like him to be off his boosted PI due to med interactions and reduce his pill burden. He is HepB negative, has had multiple STEMIs and needs to be on a aggressive statin therapy, apixaban, and PPI.. amongst other things. 

His HIV regimen is currently 10 pills with a daily total pill count of 26 pills. He also prefers smaller pills and hence is on etravirine 100mg tablets. 

This patient is currently on: 

Raltegravir 400mg BID
Darunavir 600mg BID
Ritonavir 100mg BID
Etravirine 100mg 2 tablets BID 

His ARV options are very limited:

PI - only BID boosted darunavir 
NRTI - none 
NNRTI - etravirine, rilpivirine (but is on PPI) 
INSTI - no resistance 
CCR5 tropism - testing failed the last time he was detectable many years ago 

HIV DB - Full genotype and resistances linked here 

I do not think he would tolerate CAB/RLP LA well - I suspect the ISRs and pain would be severely limiting for him.  

I have brainstormed a few options with colleagues: 

1) LEN + BIC/FTC/TAF: I do not have easy access to LEN in Canada but if I can get compassionate access and patient is ok with q6month injection. (BIC/LEN trial is not available to him) 

2) BIC/FTC/TAF + ETR bid - technically 2 fully active agents plus whatever minimal activity leftover for TAF/FTC I can get.. 

3) DTG/RLP - assuming he can come off his PPI - I do not have any experience using it in the HTE + multiple VF group, and requires meals and good compliance - makes me very nervous. Bonus is that it's a very small pill.

4) DTG + ETR bid + maraviroc - perform proviral DNA for CCR5 tropism and swap in maraviroc if possible 

5) DTG + ETR bid + fostemsavir bid - no idea how to access this in Canada currently

Any thoughts on the options above or anything else that should be considered? 

Thanks! 

I took over the care for a very treatment experienced patient (HIV for 30+ years, multiple failures prior to INSTI) with a high burden of co-morbidities.

I really would like him to be off his boosted PI due to med interactions and reduce his pill burden. He is HepB negative, has had multiple STEMIs and needs to be on a aggressive statin therapy, apixaban, and PPI.. amongst other things. 

His HIV regimen is currently 10 pills with a daily total pill count of 26 pills. He also prefers smaller pills and hence is on etravirine 100mg tablets. 

This patient is currently on: 

Raltegravir 400mg BID
Darunavir 600mg BID
Ritonavir 100mg BID
Etravirine 100mg 2 tablets BID 

His ARV options are very limited:

PI - only BID boosted darunavir 
NRTI - none 
NNRTI - etravirine, rilpivirine (but is on PPI) 
INSTI - no resistance 
CCR5 tropism - testing failed the last time he was detectable many years ago 

HIV DB - Full genotype and resistances linked here 

I do not think he would tolerate CAB/RLP LA well - I suspect the ISRs and pain would be severely limiting for him.  

I have brainstormed a few options with colleagues: 

1) LEN + BIC/FTC/TAF: I do not have easy access to LEN in Canada but if I can get compassionate access and patient is ok with q6month injection. (BIC/LEN trial is not available to him) 

2) BIC/FTC/TAF + ETR bid - technically 2 fully active agents plus whatever minimal activity leftover for TAF/FTC I can get.. 

3) DTG/RLP - assuming he can come off his PPI - I do not have any experience using it in the HTE + multiple VF group, and requires meals and good compliance - makes me very nervous. Bonus is that it's a very small pill.

4) DTG + ETR bid + maraviroc - perform proviral DNA for CCR5 tropism and swap in maraviroc if possible 

5) DTG + ETR bid + fostemsavir bid - no idea how to access this in Canada currently

Any thoughts on the options above or anything else that should be considered? 

Thanks! 

Hi William,

Wow.  Tough case.

If the goal is to remove the boosting agent and to get to the lowest pill burden, how about dolutegravir/lenacapavir/fostemsavir?  Of course, I don't know how readily available this regimen would be in Canada.  This would equal three pills a day plus an every 6 month injection, and would include three fully active agents. Feasible, but riskier, would be the above regimen without lenacapavir (dolutegravir/fostemsavir). You could conceivably use dolutegravir/3TC in place of dolutegravir if you think there might be a tad of 3TC activity and reduction in viral fitness.

I took over the care for a very treatment experienced patient (HIV for 30+ years, multiple failures prior to INSTI) with a high burden of co-morbidities.

I really would like him to be off his boosted PI due to med interactions and reduce his pill burden. He is HepB negative, has had multiple STEMIs and needs to be on a aggressive statin therapy, apixaban, and PPI.. amongst other things. 

His HIV regimen is currently 10 pills with a daily total pill count of 26 pills. He also prefers smaller pills and hence is on etravirine 100mg tablets. 

This patient is currently on: 

Raltegravir 400mg BID
Darunavir 600mg BID
Ritonavir 100mg BID
Etravirine 100mg 2 tablets BID 

His ARV options are very limited:

PI - only BID boosted darunavir 
NRTI - none 
NNRTI - etravirine, rilpivirine (but is on PPI) 
INSTI - no resistance 
CCR5 tropism - testing failed the last time he was detectable many years ago 

HIV DB - Full genotype and resistances linked here 

I do not think he would tolerate CAB/RLP LA well - I suspect the ISRs and pain would be severely limiting for him.  

I have brainstormed a few options with colleagues: 

1) LEN + BIC/FTC/TAF: I do not have easy access to LEN in Canada but if I can get compassionate access and patient is ok with q6month injection. (BIC/LEN trial is not available to him) 

2) BIC/FTC/TAF + ETR bid - technically 2 fully active agents plus whatever minimal activity leftover for TAF/FTC I can get.. 

3) DTG/RLP - assuming he can come off his PPI - I do not have any experience using it in the HTE + multiple VF group, and requires meals and good compliance - makes me very nervous. Bonus is that it's a very small pill.

4) DTG + ETR bid + maraviroc - perform proviral DNA for CCR5 tropism and swap in maraviroc if possible 

5) DTG + ETR bid + fostemsavir bid - no idea how to access this in Canada currently

Any thoughts on the options above or anything else that should be considered? 

Thanks! 

Will,

You sent me a message with a question, but I couldn't figure out how to respond. You asked about Juluca in HTE patients.  I'm not aware of good data on either DTG/RPV or CAB/RPV for this type of patient.  In theory, both regimens would offer two active drugs, but the lack of data would still make me nervous.

Hi William,

Wow.  Tough case.

If the goal is to remove the boosting agent and to get to the lowest pill burden, how about dolutegravir/lenacapavir/fostemsavir?  Of course, I don't know how readily available this regimen would be in Canada.  This would equal three pills a day plus an every 6 month injection, and would include three fully active agents. Feasible, but riskier, would be the above regimen without lenacapavir (dolutegravir/fostemsavir). You could conceivably use dolutegravir/3TC in place of dolutegravir if you think there might be a tad of 3TC activity and reduction in viral fitness.

I took over the care for a very treatment experienced patient (HIV for 30+ years, multiple failures prior to INSTI) with a high burden of co-morbidities.

I really would like him to be off his boosted PI due to med interactions and reduce his pill burden. He is HepB negative, has had multiple STEMIs and needs to be on a aggressive statin therapy, apixaban, and PPI.. amongst other things. 

His HIV regimen is currently 10 pills with a daily total pill count of 26 pills. He also prefers smaller pills and hence is on etravirine 100mg tablets. 

This patient is currently on: 

Raltegravir 400mg BID
Darunavir 600mg BID
Ritonavir 100mg BID
Etravirine 100mg 2 tablets BID 

His ARV options are very limited:

PI - only BID boosted darunavir 
NRTI - none 
NNRTI - etravirine, rilpivirine (but is on PPI) 
INSTI - no resistance 
CCR5 tropism - testing failed the last time he was detectable many years ago 

HIV DB - Full genotype and resistances linked here 

I do not think he would tolerate CAB/RLP LA well - I suspect the ISRs and pain would be severely limiting for him.  

I have brainstormed a few options with colleagues: 

1) LEN + BIC/FTC/TAF: I do not have easy access to LEN in Canada but if I can get compassionate access and patient is ok with q6month injection. (BIC/LEN trial is not available to him) 

2) BIC/FTC/TAF + ETR bid - technically 2 fully active agents plus whatever minimal activity leftover for TAF/FTC I can get.. 

3) DTG/RLP - assuming he can come off his PPI - I do not have any experience using it in the HTE + multiple VF group, and requires meals and good compliance - makes me very nervous. Bonus is that it's a very small pill.

4) DTG + ETR bid + maraviroc - perform proviral DNA for CCR5 tropism and swap in maraviroc if possible 

5) DTG + ETR bid + fostemsavir bid - no idea how to access this in Canada currently

Any thoughts on the options above or anything else that should be considered? 

Thanks! 

I took over the care for a very treatment experienced patient (HIV for 30+ years, multiple failures prior to INSTI) with a high burden of co-morbidities.

I really would like him to be off his boosted PI due to med interactions and reduce his pill burden. He is HepB negative, has had multiple STEMIs and needs to be on a aggressive statin therapy, apixaban, and PPI.. amongst other things. 

His HIV regimen is currently 10 pills with a daily total pill count of 26 pills. He also prefers smaller pills and hence is on etravirine 100mg tablets. 

This patient is currently on: 

Raltegravir 400mg BID
Darunavir 600mg BID
Ritonavir 100mg BID
Etravirine 100mg 2 tablets BID 

His ARV options are very limited:

PI - only BID boosted darunavir 
NRTI - none 
NNRTI - etravirine, rilpivirine (but is on PPI) 
INSTI - no resistance 
CCR5 tropism - testing failed the last time he was detectable many years ago 

HIV DB - Full genotype and resistances linked here 

I do not think he would tolerate CAB/RLP LA well - I suspect the ISRs and pain would be severely limiting for him.  

I have brainstormed a few options with colleagues: 

1) LEN + BIC/FTC/TAF: I do not have easy access to LEN in Canada but if I can get compassionate access and patient is ok with q6month injection. (BIC/LEN trial is not available to him) 

2) BIC/FTC/TAF + ETR bid - technically 2 fully active agents plus whatever minimal activity leftover for TAF/FTC I can get.. 

3) DTG/RLP - assuming he can come off his PPI - I do not have any experience using it in the HTE + multiple VF group, and requires meals and good compliance - makes me very nervous. Bonus is that it's a very small pill.

4) DTG + ETR bid + maraviroc - perform proviral DNA for CCR5 tropism and swap in maraviroc if possible 

5) DTG + ETR bid + fostemsavir bid - no idea how to access this in Canada currently

Any thoughts on the options above or anything else that should be considered? 

Thanks! 

I took over the care for a very treatment experienced patient (HIV for 30+ years, multiple failures prior to INSTI) with a high burden of co-morbidities.

I really would like him to be off his boosted PI due to med interactions and reduce his pill burden. He is HepB negative, has had multiple STEMIs and needs to be on a aggressive statin therapy, apixaban, and PPI.. amongst other things. 

His HIV regimen is currently 10 pills with a daily total pill count of 26 pills. He also prefers smaller pills and hence is on etravirine 100mg tablets. 

This patient is currently on: 

Raltegravir 400mg BID
Darunavir 600mg BID
Ritonavir 100mg BID
Etravirine 100mg 2 tablets BID 

His ARV options are very limited:

PI - only BID boosted darunavir 
NRTI - none 
NNRTI - etravirine, rilpivirine (but is on PPI) 
INSTI - no resistance 
CCR5 tropism - testing failed the last time he was detectable many years ago 

HIV DB - Full genotype and resistances linked here 

I do not think he would tolerate CAB/RLP LA well - I suspect the ISRs and pain would be severely limiting for him.  

I have brainstormed a few options with colleagues: 

1) LEN + BIC/FTC/TAF: I do not have easy access to LEN in Canada but if I can get compassionate access and patient is ok with q6month injection. (BIC/LEN trial is not available to him) 

2) BIC/FTC/TAF + ETR bid - technically 2 fully active agents plus whatever minimal activity leftover for TAF/FTC I can get.. 

3) DTG/RLP - assuming he can come off his PPI - I do not have any experience using it in the HTE + multiple VF group, and requires meals and good compliance - makes me very nervous. Bonus is that it's a very small pill.

4) DTG + ETR bid + maraviroc - perform proviral DNA for CCR5 tropism and swap in maraviroc if possible 

5) DTG + ETR bid + fostemsavir bid - no idea how to access this in Canada currently

Any thoughts on the options above or anything else that should be considered? 

Thanks!