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  • 1.  Treatment Experienced, HIV+, Mutation Inquiry

    Posted 5 days ago

    Hello everyone,

    Hoping for input on a case that I have been working on recently. 

    HIV MALE 76YO

    On Biktarvy + Pilfelto, reports taking oral medications daily but based on recent genosure results, concerned for non compliance

    Has had the following HIV RNA VL: 09/2025 - 91 , 10/2025 - 111 , 01/2026 171

    Due to rising VL without missed doses (as reported by the patient), ran genosure archive showing resistance to Raltegravir

    RT --> V60I,R83K, Q102K, I135T, C162S,R277K, T286A, M357V, K358R,, T386I, A400T

    IN -->S39C, V72I, L101I, V113I, T124A, T125A, Y143Y/H, D167E, K173R, I182V, V201I, V234L, D278E

    Previous genotyping from Quest 03/2025 shows: M184V + I13V and V771

    M184V not appreciated on Genosure Archive from Labcorp in 01/2026

    After researching mutations listed above, it appears that the Biktarvy+Pilfeltro regimen should be keeping the patient suppressed. Is there anything I may be missing



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    Victoria Cesar MSN, APRN, FNP-C, AAHIVS
    Titusville FL
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  • 2.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 5 days ago
    Based on the GenoSure Archive, his current regimen should be fully suppressive. In fact, Biktarvy alone should also be fully suppressive, since both the BIC and TAF components are active. Therefore, I'd be concerned about his adherence, but would also make sure he's not taking divalent cations (antacids, calcium or iron supplements) without appropriate dosing separation, since they could affect BIC absorption.

    Keep in mind that the GenoSure Archive can miss important mutations. If you have access to old resistance tests, they could be helpful to make sure there's nothing missing. And if his viral load climbs further to at least 500, I'd order a standard genotype.



    Original Message


  • 3.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 5 days ago
    Based on the GenoSure Archive, his current regimen should be fully suppressive. In fact, Biktarvy alone should also be fully suppressive, since both the BIC and TAF components are active. Therefore, I'd be concerned about his adherence, but would also make sure he's not taking divalent cations (antacids, calcium or iron supplements) without appropriate dosing separation, since they could affect BIC absorption.

    Keep in mind that the GenoSure Archive can miss important mutations. If you have access to old resistance tests, they could be helpful to make sure there's nothing missing. And if his viral load climbs further to at least 500, I'd order a standard genotype.



    Original Message


  • 4.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 4 days ago

    I'd like to expand on Dr. Gallant's comments regarding polyvalent cations.

    Is this patient taking his meds with dairy milk, fortified plant milk, fortified orange juice, nutritional drinks like Ensure, or even electrolyte drinks or preworkout powder mixes while fasted?



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    Steven Psaros
    Shelby Township MI
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    Original Message


  • 5.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 4 days ago
    I'm not aware of any of those things being a problem. What you're describing are foods, and there are no food restrictions with the regimen he's taking.




    Original Message


  • 6.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 4 days ago

    Hello Dr. Psaros. Thank you for your reply. At this time, I do not believe he is taking any of the noted foods above. I will check with him at his upcoming appointment. Would these foods decrease absorption of Biktarvy? If so, how long between these foods and Biktarvy administration should the patient wait? Thank you!



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    Victoria Cesar
    Titusville FL
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    Original Message


  • 7.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 4 days ago

    Victoria,

    These foods will not interfere with Biktarvy absorption.  There are no food restrictions with Biktarvy--only restrictions on specific antacids and supplements that contain divalent cations. I would not ask him about this, as it will only confuse or worry him.  Biktarvy should be easy for patients to take; there's no need to complicate things unnecessarily!



    ------------------------------
    Joel Gallant, MD, MPH
    Johns Hopkins University
    Baltimore, MD

    AXCES Research Group
    Santa Fe, NM
    ------------------------------

    Original Message


  • 8.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 4 days ago

    I have been reading these forums for years and appreciate very much Dr. Gallant's contributions.  I probably learned more from him than anyone else on this forum.  Additionally, I wholeheartedly agree with him on this thread, especially keeping clear of complicating matters and avoiding confusion for the patient.  I was throwing out a possibility that is unlikely, but could be helpful.  Even though there are no food restrictions with bictegravir including taking it with milk, some patients have some strange ways they take their medications.  Recently I had a non HIV patient that takes all his meds with a preworkout powder.  Can you imagine a patient taking a preworkout powder in a hospital bed?  When I saw the container, I noticed it had 1250 mg calcium per serving, more than any antacid I am aware of.  Had he been on thyroid meds or doxycycline, he would diminish the effects of those drugs.  This is just a recent example and the most recent oddity I came across.   Anyway, the lesson here is our patients are diverse and their habits will sometimes surprise us.



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    Steven Psaros
    Shelby Township MI
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    Original Message


  • 9.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 3 days ago

    Steven

    Thanks for your comments. Keep in mind that the thousands of patients who have taken Biktarvy in clinical trials didn't take it from hospital beds, but took it in their daily lives, with instructions to take it without regard for food. The only instructions they were given related to the antacids and supplements mentioned in the package insert. Having conducted many trials myself, I can say with certainty that many trial participants were taking supplements like the ones you describe, as well as milk, orange juice, and Ensure, and it obviously didn't affect outcome.

    One of the reasons that Biktarvy works so well is that it's so easy to adhere to.  You can take it any time of the day with or without food. If we make that more complicated than it needs to be, I worry that adherence will decline, and that's more likely to affect viral suppression than any calcium that might be in whatever they're taking.



    ------------------------------
    Joel Gallant, MD, MPH
    Johns Hopkins University
    Baltimore, MD

    AXCES Research Group
    Santa Fe, NM
    ------------------------------

    Original Message


  • 10.  RE: Treatment Experienced, HIV+, Mutation Inquiry

    Posted 3 days ago
    We have a lot of very knowledgeable contributors to this forum, Steven, so I don’t want to take anything away from any of them, but I have to agree with you that I have consistently found Dr. Gallant’s contributions to be pearls of wisdom and experience, and I hope he stays involved for the benefit of all of us.

    Stephen


    Sent from my iPhone


    Original Message


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