Optimizing Treatment

Considerations When Optimizing Regimens

A variety of important factors should be considered in the treatment decision

Providers may hesitate to change a patient’s regimen, but there may be compelling reasons to do so, including1:

Reducing pill burden

Tolerability and toxicity considerations

Potential drug-drug interactions

Food requirements

Patient access

Barrier to resistance

According to the DHHS guidelines, the fundamental principle of regimen optimization is to maintain viral suppression without jeopardizing future treatment options.1

A regimen’s barrier to resistance is important to consider when choosing a treatment, even if a patient is virally suppressed1

As discussed in the DHHS guidelines, the SWITCHMRK 1 and 2 studies illustrated the importance of considering the possibility of underlying drug resistance before switching therapy in those with virologic suppression. This is particularly important when the new regimen may not include three fully active agents and when the new regimen may have a lower overall barrier to resistance.1

Resistance Is Permanent and Irreversible1

Preexisting resistance is a critical consideration when switching ART in virologically suppressed PLWH

Longer duration of ART is a factor associated with developing resistance.2 In a 2023 survey that included PLWH over the age of 50 or living with HIV for more than 15 years (N=673), the reported average number of years on ART was 23.3

M184V/I is one of the most common resistance mutations associated with treatment failure4:

The M184V/I resistance mutation was present in 31% of samples with any drug resistance mutation in a 2017 analysis from a large US database.4,*

M184V/I reduces susceptibility to some NRTIs >200-fold and increases susceptibility to other NRTIs.5,6

Commercial resistance assays may fail to detect a mutation if it constitutes less than 20% of circulating virus.1 Genotypic identification of resistance mutations, including M184V/I, may be complicated by the reemergence of wild-type virus in the absence of selective pressure from HIV treatment.1,7

*The analysis for 2017 included about 10,000 samples. The number of samples with any drug resistance mutation was not provided.

Before switching therapy in the setting of virologic suppression, it's important to consider underlying resistance and review full ART history, including virologic response.1

How do you approach real-world discussions for switching treatments?

Having conversations around optimizing regimens can help providers and patients who are assessing their options.

Wide Diversity in Clinical Trial Data May Help Inform Treatment Discussions

Increasing the amount of clinical trial data available for specific populations may enhance patient trust8

Increasing diversity and inclusion in clinical trials can provide more generalizable evidence—potentially improving patient trust and advancing health equity. Enhanced patient trust can lead to better retention in care, especially when patients are included as partners.8

While every patient is different, people living with HIV may be inclined towards taking a collaborative approach to shared clinical decision-making.

7 out of 10 patients preferred to engage in shared decision-making in a 2010 study

In a 2010 study, 7 out of 10

patients preferred to engage in shared decision-making when it came to their HIV treatment (n=434)9

Please see full Prescribing Information for BIKTARVY® and DESCOVY®, including BOXED WARNINGS.

DHHS, US Department of Health and Human Services

Reference: 1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Department of Health and Human Services. Updated December 06, 2023. Accessed December 07, 2023. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf 2. Pennings PS. HIV drug resistance: problems and perspectives. Infect Dis Rep. 2013;5(Supp 1):e5. 3. Health HIV. State of Aging with HIV Third Annual National Survey. Accessed November 9, 2023. https://healthhiv.org/stateof/agingwithhiv/ 4. Kagan RM, Dunn KJ, Snell GP, et al. Trends in HIV-1 drug resistance mutations from a U.S. reference laboratory from 2006 to 2017. AIDS Res Hum Retroviruses. 2019;35(8):698-709. 5. Stanford University Drug Resistance Database. NRTI resistance notes. Updated October 25, 2023. Accessed November 9, 2023. https://hivdb.stanford.edu/dr-summary/resistance-notes/NRTI/ 6. Geretti AM, Blanco JL, Marcelin AG, et al. HIV DNA sequencing to detect archived antiretroviral drug resistance. Infect Dis Ther. 2022;11(5):1793-1803. 7. Boettiger DC, Kiertiburanakul S, Sungkanuparph S, et al. The impact of wild-type reversion on transmitted resistance surveillance. Antivir Ther. 2014;19(7):719-722. 8. Corneli A, Hanlen-Rosado E, McKenna K, et al. Enhancing diversity and inclusion in clinical trials. Clin Pharmacol Ther. 2023;113(3):489-499. 9. Kumar R, Korthuis PT, Saha S, et al. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med. 2010;25(6):517-523.