Each year, the number of people living with HIV increases while the available HIV workforce decreases. As a result, primary care providers (PCPs), nurse practitioners (NPs), and physician associates (PAs) are increasingly involved in the care of people living with HIV.
And there are data that prove it: In one survey, NPs were more likely than infectious disease (ID) physicians to care for more than 50 people living with HIV and to spend more than 30 hours each week caring for these patients. NPs also reported providing more comprehensive HIV care that included adherence support, reproductive counseling, and risk‐reduction services.
Increasingly potent and simplified antiretroviral therapy (ART) options have made HIV treatment initiation and ongoing care feasible for PCPs and non-ID specialist healthcare professionals (HCPs), which can be supported by using the HIV-ASSIST tool.
One of the primary goals of HIV treatment is viral suppression. Rapid control of viral replication benefits the person living with HIV by helping preserve immune function and reducing the risk of HIV transmission. Department of Health and Human Services (DHHS) HIV treatment guidelines recommend starting ART as soon as possible after HIV diagnosis, even before other laboratory data (eg, HIV genotype) become available. In these situations, it is recommended to initiate a regimen that has a high barrier to resistance, is well tolerated, and has demonstrated efficacy in rapidly lowering HIV viral load.
HIV-ASSIST can help guide HCPs in making an informed decision on which ART regimen to initiate in a person newly diagnosed with HIV. Let’s look at a case example to illustrate how HIV-ASSIST can be beneficial in selecting a regimen for a person newly diagnosed with HIV when other laboratory test results are not yet available.
A 26-year-old cisgender man is referred to your care for a new diagnosis of HIV. His last negative HIV test was 6 months ago. His medical history includes mild persistent asthma, for which he uses inhaled fluticasone daily and inhaled albuterol as needed. He has never been on HIV pre-exposure prophylaxis. His preference for treatment is one that is dosed as a single tablet once daily. His baseline laboratory results are pending.
HIV-ASSIST Supports Treatment Decisions for Rapid ART Initiation
This patient’s information, including his comedications and preference for once daily dosing, can be entered into HIV-ASSIST for guidance on initial ART. The viral load, CD4 count, and HLA-B*5701 laboratory value fields allow you to mark that they are unknown (Figure 1).
Figure 1: HIV-ASSIST input for a person newly diagnosed with HIV.
Based on input of this patient’s data, HIV-ASSIST provides a scored ranking of regimen options for this specific patient (Figure 2).
Figure 2: HIV-ASSIST output options for ART rapid initiation.
Preferred regimens have a lower weighted score and are coded in dark green. Here we see that bictegravir (BIC)/tenofovir alafenamide (TAF)/emtricitabine (FTC) and dolutegravir (DTG) plus TAF/FTC are at the top of the preferred list and are equally weighted with a score of 1. A differentiating factor is that BIC/TAF/FTC is available as a single tablet regimen compared to DTG plus TAF/FTC, which requires a person to take 2 pills daily.
If you were to consult only the DHHS HIV treatment guidelines for initiating therapy in this patient (a person newly diagnosed with HIV who does not yet have baseline lab results), you would see several recommended options, including: BIC/TAF/FTC, DTG with either TAF or TDF plus either FTC or 3TC, or boosted darunavir (DRV)/ritonavir (RTV) with TAF or TDF plus FTC or 3TC.
However, HIV-ASSIST has prioritized the 2 integrase strand transfer inhibitor (INSTI)-based regimens above the boosted DRV regimen. And HIV-ASSIST gives DRV/cobicistat (COBI)/TAF/FTC and DRV/RTV+TAF/FTC lower priority, primarily because of the drug–drug interaction between the patient’s inhaled corticosteroid and boosted DRV.
Clicking on any one of the regimens will bring you to an Education Sheet that will show a summary of the data and recommendations for that regimen, its dosing information, and rationale for the scoring (Figure 3).
Figure 3: Scoring rationale for DRV/COBI/TAF/FTC in this scenario.
One of the benefits of HIV-ASSIST is that it pulls in information from other sources, such as the University of Liverpool’s drug–drug interaction tool, which enhances treatment decisions that may not be apparent by relying solely on the DHHS guidelines.
The potential risk for drug–drug interaction between boosted PIs and corticosteroids—even those that are inhaled—is significant. Patients who are using corticosteroids chronically and are also on CYP3A inhibitors such as COBI or RTV may experience adverse events. These CYP3A inhibitors can increase circulating drug levels of corticosteroids resulting in the possibility of Cushingoid effects and/or adrenal suppression.
In this scenario, rapid initiation of ART with BIC/TAF/FTC was chosen. Not only does this regimen have few drug–drug interactions relevant to this patient, but it is also available as a once-daily single tablet regimen, which the patient noted as a preference.
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