The combination of LEN and CAB is generally used for people who can't be suppressed on oral therapy due to poor adherence. This man, on the other hand, is essentially suppressed on a complex oral regimen, and takes lots of oral medications for other medical problems. I don't see the need for a long-acting injectable regiment in his case, especially since CAB has a lower resistance barrier than DTG or BIC.
That being said, his regimen could easily be simplified. Switching from RAL to DTG would be a good start, and you'd be increasing the resistance barrier of his regimen. Another possibility would be to switch from Rukobia twice daily to LEN twice yearly. As for DRV, he has one DRV mutation (84V), which means that he's supposed to take DRV/r twice daily rather than DRV/c once daily. Whether he needs the PI at all is debatable though, since his virus should be fully susceptible to DTG and LEN. But maybe it's best not to make all three changes at the same time.
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Joel Gallant, MD, MPH
Johns Hopkins University
Baltimore, MD
AXCES Research Group
Santa Fe, NM
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Original Message:
Sent: 12-16-2025 11:36
From: Jenny Tan
Subject: Treatment Experience Pt: Next regimen?
57 y/o wheelchair bound patient history of HIV (dx in 1992), stroke, diabetes and seizure disorder due to a stroke. I recently inherited the patient and he is interested in simplification of his regimen as he is having adherence issues. He is interested in injectable options and we have discussed putting him on Lenacapavir q6months and Cabotegravir q2months
Labs:
VL 36 (11/2025) prior to was 76 (9/2025) but noted to have intermittently high VL in the past.
CD4 454/23.5%
Renal function and hepatic function normal.
Current ARV Regimen:
Isentress 400mg BID
DRV/r 600/100mg BID
Rukobia 600mg BIE
Other meds:
Atorva 10mg
Keppra 500mg BID
Gabapentin 300mg BID
Metformin 625mg daily
ASA 81mg daily
I've inputed the mutations in the Stanford database from all the resistance testing we have on file and from Monogram.
Also included is the most recent GS archive from 11/2025 as I am able to get a GT as his VL has been low. Given he is on RAL, I was concerned he may have some INSTI resistance but no INSTI mutations noted on GS archive.
Possible regimens:
- Lenacapavir q6 months and Cabotegravir q2 months (+/- boosted DRV)
- Symtuza and Dolutegravir daily
Questions:
- Is Len/Cab a reasonable regimen for the patient?
- Since the GS Archive did not show INSTI mutations, should I be concerned that I am missing it given he is on RAL despite the low VL? If this is the case, should pt also get boosted Darunavir as an addition to the Len/Cab regimen?
- The pt has 1 DRV associated mutations, should DRV be given as a BID dose with 1 mutation or can it given as 800mg daily dose?
- Any other recommendations or thoughts for a more simplified regimen?
Thank you for the assistance.
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Jenny Tan
CA
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