Continued viremia on INSTI+PI

Mutations: M184V, M41L, K103N, L63P, V77I, I93L, K101Q, D60E, I64L
Comorbidities: None
Comedications: None
Treatment history: 3TC (Lamivudine/Epivir) , D4T (Stavudine/Zerit) , ATV (Atazanavir/Reyataz) , TDF/FTC (Truvada)
Current regimen: ATV/c (Atazanavir-cobicistat/Evotaz) , DTG (Dolutegravir/Tivicay) , TAF/FTC (Descovy)
Adherence: Patients with pill aversion (prioritize smaller pills), Patients with intermittent adherence, Penalize regimens with IV/IM dosing
CD4: ≤ 50
Viral load: High (100,000 - 500,000)
HLA-B5701: Negative
Tropism: R5 virus
View results
Submitted by maunank on Wed, 06/03/2020 - 16:57

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.

History of

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)
DTG+DRV/c/TAF/FTC -0.4 3 2 1
DTG+DRV/r+TAF/FTC -0.1 3 4 1
DRV/c+BIC/TAF/FTC 0.6 3 2 1
DRV/r+BIC/TAF/FTC 0.7 3 3 1
DTG+DRV/c 1.3 2 2 1
Ask on the National Clinical Consultation Center

Comments

Submitted by maunank on Wed, 06/03/2020 - 17:20

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.