Academy Exchange

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hi Ryan

from someone who has been providing HIV care since 1989 out of residency, I would say an important piece with a NEW patient is to go gingerly with them when it comes to medication change (ART) - especially when they have been doing well (VL < 20/ CD4 -700) on their current regimen and their prior doctor did not (likely) recommend a change. Biktarvy from a renal perspective makes sense and hopefully something he would understand if explained carefully.  Many of my older long-term patients who used to come in monthly and then q3 or q6 months with simplified safer regimens -  also started requesting yearly visits. Although our Ryan White Clinic has a 6-month visit policy -  I generally agreed to yearly visits for some patients -  with the caveat being they would get "safety/ screening labs) at a 6 month interval but would not need an office visit.  The other challenge with aging HIV patients is then addressing co-morbidities which can be difficult with only once visit a year. "Dance" with them -- and once they have gained trust and confidence you should be able to do what is clinically best for them.

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Jeffrey, 

Thank you for your reply, I greatly appreciate it. Great insight. I have seen this patient a couple of times and he expresses interest in a switch but is quite ambivalent about making a change, it may take time to continue developing rapport and trust with him. 

Thanks again!

Ryan

Hi Ryan

from someone who has been providing HIV care since 1989 out of residency, I would say an important piece with a NEW patient is to go gingerly with them when it comes to medication change (ART) - especially when they have been doing well (VL < 20/ CD4 -700) on their current regimen and their prior doctor did not (likely) recommend a change. Biktarvy from a renal perspective makes sense and hopefully something he would understand if explained carefully.  Many of my older long-term patients who used to come in monthly and then q3 or q6 months with simplified safer regimens -  also started requesting yearly visits. Although our Ryan White Clinic has a 6-month visit policy -  I generally agreed to yearly visits for some patients -  with the caveat being they would get "safety/ screening labs) at a 6 month interval but would not need an office visit.  The other challenge with aging HIV patients is then addressing co-morbidities which can be difficult with only once visit a year. "Dance" with them -- and once they have gained trust and confidence you should be able to do what is clinically best for them.

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

I'm an HIV Peer Educator at University Health in Kansas City, MO I just switched from Genvoya to Biktarvy after a year of watching patients blood labs and how fast they change. My CD4 has not been over 400 since my diagnosis in 2010. I'd been on Genvoya for almost 10 years and had no interest in changing my meds until I saw results in the lab changes of newly diagnosed patients and the drastic changes in viral loads and CD4's. Ambivalence in patients comes from their lack of education as well as them not feeling any different on ART VRS or not. I believe seeing results will help this patient and others get on board with changing meds. 

------------------------------
Brooke Davidoff
Kansas City MO

Original Message:
Sent: 04-04-2024 06:20
From: Ryan Doyle
Subject: Therapy Switch

Jeffrey, 

Thank you for your reply, I greatly appreciate it. Great insight. I have seen this patient a couple of times and he expresses interest in a switch but is quite ambivalent about making a change, it may take time to continue developing rapport and trust with him. 

Thanks again!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI

Original Message:
Sent: 04-02-2024 15:33
From: Jeffrey Kirchner
Subject: Therapy Switch

Hi Ryan

from someone who has been providing HIV care since 1989 out of residency, I would say an important piece with a NEW patient is to go gingerly with them when it comes to medication change (ART) - especially when they have been doing well (VL < 20/ CD4 -700) on their current regimen and their prior doctor did not (likely) recommend a change. Biktarvy from a renal perspective makes sense and hopefully something he would understand if explained carefully.  Many of my older long-term patients who used to come in monthly and then q3 or q6 months with simplified safer regimens -  also started requesting yearly visits. Although our Ryan White Clinic has a 6-month visit policy -  I generally agreed to yearly visits for some patients -  with the caveat being they would get "safety/ screening labs) at a 6 month interval but would not need an office visit.  The other challenge with aging HIV patients is then addressing co-morbidities which can be difficult with only once visit a year. "Dance" with them -- and once they have gained trust and confidence you should be able to do what is clinically best for them.

------------------------------
Jeffrey T. Kirchner, DO, FAAFP, AAHIVS
Lancaster PA

Original Message:
Sent: 04-02-2024 05:54
From: Ryan Doyle
Subject: Therapy Switch

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hi Ryan,

Good question.   In a case like this, it is all about the "art" of medicine.  There are no "right" answers.

For me, I would prefer to have this guy on an unboosted regimen.  As he gets older and accumulates additional morbidities, he will likely need additional medications, and the risk of significant DDIs grows if he stays on Genvoya.  Also, you would want to make sure his lipds are not elevated from this as well. That being said, if he is really attached to this med and is doing well, than I really don't see an overwhelming reason to push it.  That could threaten his trust in you.   If you do end up switching, I am not particularly concerned about the switch to Biktarvy.  You would be switching from a low barrier to resistance regimen to a high one.  Sure.  It would be great to get one visit in a few months after he changes to assure tolerability. But once again, if he is opposed to this, I would not push it that hard.   You could just ask him to call you if he experiences any issues.   Thanks!

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Switching the patient off Genvoya is probably a great idea - more to avoid the now unnecessary cobicistat boosting and the increased risk of elvitegravir virologic failure. If this patient already has CKD3a, I would seriously consider a TDF/TAF-sparing regimen, such as DTG/3TC or DTG/RPV to avoid any further exposure to TDF. If he has no prior history of VF, the TANGO study results support this switch.

David

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hi - thanks for your question.  I often grapple with this question - I have several pts on genvoya who do not want to switch to BIk or a newer ARV.  If their current labs are stable, they are adherent, and this is no contraindication to stay on genvoya - I keep them on genvoya.   When I see them at their visits - I do raise the issue of switching regimens.  I dont think it is a bad thing to keep the pt on genvoya if s/he is stable and other parameters are wnl.

Hope this helps.

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Genvoya was a great regimen in its day, but it has essentially been replaced by Biktarvy for lots of good reasons: Biktarvy is a smaller pill with no food restrictions, fewer gastrointestinal side effects, far fewer drug interactions, and a higher barrier to resistance. In contrast, I can't think of any advantage of Genvoya over Biktarvy, other than that you can get away with lower doses of Viagra.  

I had a number of patients who only wanted to be seen once a year, but they were willing to get their bloodwork drawn more often (e.g. every 6 months). Would your patient consider that?

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------

Hello, 

I have a patient who recently transferred care to me who has been on Genvoya for many years and has been doing well with respect to control of HIV, always virally suppressed and great CD4 count (most recent CD4 >700). Patient does have CKD3a. We were recently discussing switching from Genvoya to Biktarvy as an option as patient may be interested, however patient is also very hesitant to come in for visits more frequently than annually for wellness visits. I am open to switching the patient to Biktarvy, however I am concerned about his willingness to attend closer follow up after the switch to assess for adherence and obtain follow up labs. Curious if others have thoughts? I have discussed with the patient given ongoing adequate control of HIV, there may not be indication/need to make a regimen change. 

Thanks!

Ryan

------------------------------
Ryan K. Doyle, DO (he/him/his)
rymed89@gmail.com
Grand Rapids, MI
------------------------------