I'm not going to answer your question directly. I've negotiated with patients over frequency of lab monitoring before, but I've never had a patient refuse labs altogether. What I will say is that you should be using a higher barrier regimen in someone who isn't being monitored regularly, and Genovya doesn't qualify. Regimens like Biktarvy or Tivicay/Descovy would be preferred, since even if he fails those regimens, he's unlikely to develop drug resistance.
------------------------------
Joel Gallant, MD, MPH
Santa Fe, NM
------------------------------
Original Message:
Sent: 08-09-2024 13:15
From: Nathan Tapio
Subject: Unmonitored ART?
Colleagues
Looking for any insight re: HIV patient with routine lab monitoring.
Pt in question is 44 yr old male, HIV since 2005, otherwise suppressed on Genvoya. last labs just over 1 year ago. He refuses lab work secondary to "religious restrictions." He has been involved with case management for 9 years. Case management feels his disposition/mood has changed. Exam is unremarkable. We've given a few refills, however he is over 1 year from lab work, previously undetecable with normal CD-4. Previously compliant. He sees psychiatry re: schizoaffective d/o. Mostly compliant with antipsychotics.
My question being at what point can/should we refuse prescriptions? He has informed and seems to understand risks of not monitoring the disease state. It's unclear if the belief is founded v. delusions/paranoia. He presents to visits. Any thoughts/suggestions moving forward? We thought to perhaps involve the religious leader if willing for a possible exemption or permission as well as a second opinion. We've offered a letter and alternate site lab testing.
------------------------------
Nathan Tapio
Strongsville OH
------------------------------