Academy Exchange

 View Only

  • 1.  Failure on Biktarvy? What next?

    Posted 05-12-2025 19:27

    Hello,

    I have a 45 y/o HIV+ male dx in 2005 with HTN, CKD Stage 3 and HTN.  He is noted to to have fluctuating VL since 6/2024 as follows.

    5/2025:  235

    3/2025: 307

    1/2025: 119

    11/2024: 255

    6/2024: 151

    12/2023: VL<20

    10/2023: 345

    Pt swears adherence.  Denies MVI or other OTC/supplements.  He does not have previous resistance tests available on file.  PRevious ARV noted to be Truvada and EFV, Truvada and DRV/r, ABC/3TC 150mg, DRV/r, Descovy and DTG and now Biktarvy.

    Meds:

    Wellbutrin XL 150mg

    Lurasidone 80mg

    Losartan 100mg

    BIktarvy

    Nifedipine ER 90mg.

    Questions:

    1. Pt looks to have failed Biktarvy with his current VL with reported adherence.  I am not sure how to proceed from here.  I am considering switching him off Biktarvy and starting Symtuza.  The other option is to intensify his regimen with adding Prezcobix to Biktarvy but I would like to simplify his regimen as much as possible.
    2. I would appreciate your thoughts and recommendations regarding this pt.

    Thank you.



    ------------------------------
    Jenny Tan
    CA
    ------------------------------


  • 2.  RE: Failure on Biktarvy? What next?

    Posted 05-13-2025 15:19

    Jenny

    I wouldn't necessarily conclude that's your patient is failing Biktarvy.  True failure results in a progressive rise in viral load, whereas his has been stable for several years. Some people have chronic low-level viremia for reasons that are not always clear. In many cases, it's due to release of non-replicating virus from reservoir cells. Intensification studies typically found no reduction in viral load with addition of an agent from an entirely new class--strong evidence that the virus being detected is not replicating.  

    Here are some options to consider:

    1. Make sure he's not taking antacids or supplements with divalent cations at the wrong times, since they could interfere with bictegravir absorption.
    2. Consider getting a proviral DNA genotype (Archive) to look for resistance that could affect his response to this regimen. This is especially important because he's been on a lot of prior regimens and you have no resistance data.
    3. If you do decide to intensify his regimen (with Prezcobix, for example), I would frame it as a short-term experiment.  If he still has low-level viremia on an intensified regimen after a month or two, then you've demonstrated that the problem is not ongoing viral replication or the regimen he's taking, and you can go back to Biktarvy alone.

    Good luck!



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

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

    Original Message


  • 3.  RE: Failure on Biktarvy? What next?

    Posted 05-14-2025 15:28

    Hi Jenny:

    In addition to what Joel has stated, I would also not assume that you can't find old records.  This is the biggest mistake I see from HIV providers, not digging deep enough in the records.  You can train your MA or LVN to assist the patient in remembering the names of his past providers or clinics, but even more helpful, sometimes, you can call Monogram and ask them if they have any old resistance tests on file.  Their number is: 1-800-777-0177.  Try it out if you've never done it and see if they can't locate any old resistance tests.  Good luck!

    James



    ------------------------------
    James Adams
    Rancho Mirage CA
    ------------------------------

    Original Message


Related Content