Jenny,
The two regimens you mentioned should work on the basis of the genotype information you have now. Of the two, Prezcobix + lenacapavir would be much easier for him, especially if there are adherence concerns. However, given that this patient has 35 years of ART history, it's also possible that the recent genotypes are underestimating resistance, especially to the PIs. If he hasn't been on a PI for a long time, then he may have more PI resistance that what they're showing you.
Ideally, you would be able to review his complete ART history, including all past genotypes, to make that assessment, although I realize that's not always possible. If it will take time to track down old records, I would be tempted to put him on Prezcobix, fostemsavir, and give him a dose of lenacapavir, which would cover him for six months while you try to sort things out. If the PI genotype turns out to be consistent with his old records, you could then consider stopping either the lenacapavir or the fostemsavir (whichever he likes least). If records cannot be obtained, I might order a GenoSure Archive after his viral load becomes suppressed on the new regimen, recognizing that it's an imperfect test.
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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: 10-29-2025 19:13
From: Jenny Tan
Subject: Re: Multidrug Resistant Pt
Hello,
35 y/o male perinatally infected with HIV noted for multidrug resistant HIV. Attached is the Standford database information with the mutations on all the resistance test I've gathered from our clinic and through Monogram.
Pt is currently on Biktarvy. Most recent VL as of 10/16/2025 at 135K with a CD4 46/7.8%. Pt established care in the clinic in 2023 and has been on Biktarvy since with an initial VL of 1.6 million and CD4 2.
VL decreased to 274 (11/2023) and 70 in 2/2024.
VL increased again to 253K in 6/2024 with intermittent adherence to med-->174K in 12/2024. Resistance testing at this time did not show Integrase resistance but had multiple NRTI/NNRTI mutations, suspectible only to AZT, PI-susceptible to DRV, no INSTI mutations.
VL has since been significantly elevated since and I did not get a repeat GT until 10/2025 which showed the new Integrase mutations.
Questions:
- For his next regimen, is it reasonable to change to Prezcobix and Fostamsevir BID for now, which will provide 2 fully active agents?
- We also discussed changing to Prezcobix and Lenacapavir. I've never started pt on a Lenacapvir based regimen before and not sure how difficult it is to get the medication for the patient.
- Any other recommended regimen at this time?
I would appreciate any thoughts or recommendations.
Thank you.
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Jenny
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