50 y.o. female with a history of HIV (CD4 9, VL 180,000, (2020)), supposedly on Descovy, Evotaz, and DTG, but with many and repeated problems c non compliance. Also c hx CMV enteritis and VZV opthalmicus w/ associated complete blindness since 2003, anemia, DM (on metformin and previously on glipizide), hx/o DRESS Syndrome (presumed 2/2 dapsone), hypertension, hypothyroidism (Graves s/p radioactive iodine), prior DVT.
Nelvinavir, combivir--failed, M184V
D4T, 3TC, ATZ/r--supppressed and then failed: M184V, L63, V77I
Truvada+ATV/r--suppressed then failed. Similar genotype, K101Q and M41L eventually
TDF, RAL, ATV/r--Similar genotypes
Switches from RAL to DTG and later to descovy,prezcobix, DTG but considered the prezcobix to be too big and wanted to continue evotaz
|Regimen||Weighted Score||Active Drugs||Total Pills||Frequency (x/day)|
This patient has a long history of ATV usage despite the lack of demonstrated resistance. With the noted resitsance pattern and many genotypes, this suggests lack of taking meds rather than intermittent treatment to me. In the absence of INSTI resistance, just the TAF/FTC+DTG should likely have been sufficient, or DTG+ATV/c, to suppress. The continued viremia seems to suggest she is not on the meds, and I do think a repeat genotype after starting medications could be informative. Given the long history of ATV usage, I would be suspicious of using ATV. I do think that in this patient I would consider trying to include 2+ active drugs in the regimen inclusive of both an INSTI and a PI, and DRV would be preferred. In the POWER study, which included treatment-experienced patients with at least one PI mutation, participants did quite a bit better with DRV than other PI's. On the chance that there is some PI resistance that has not been detected, I would favor DRV over continuing the ATV. While there is limited data on using a 4 drug regimen, the listed regimens by HIVASSIST seem reasonable and without substantial pill burden. E/C/F/TAF+DRV has been studied as a switch study (Huhn et al. PMID 27753684) in suppressed patients with background 2-3 class resistance and prior regimen failures. BIC/TAF/FTC has not been studied as extensively in treatment experienced patients and so I generally favor the approach of DTG+DRV/c/TAF/FTC. With that said, there is emerging data on the ability of BIC/TAF/FTC to maintain suppression even with background NRTI resistance, and pairing it with DRV is likely to be a robust regimen.