Choosing a New Treatment Regimen for Patients With HIV

In this podcast, Daniel Kuritzkes, MD, speaks about new medications available for patients with HIV, as well as the factors patients with HIV should consider when choosing a new regimen. He also details how clinicians should define those with limited treatment options and the ways to manage patients with HIV who have few treatments to choose from. Dr Kuritzkez also participated in a symposium on these topics titled "Managing HIV Patients With Limited Treatment Options" at IDWeek 2022. 

This podcast was recorded before IDWeek 2022. 

Additional Resource:

• Kuritzkes DR, Gandhi M, Flexner CW. Managing HIV patients with limited treatment options. Talk presented at: IDWeek 2022; October 19-23, 2022; Washington DC. Accessed October 19, 2022. 

Daniel Kuritzkez, MD, is the Chief of the Division of Infectious Diseases at Brigham and Women’s Hospital and Harriet Ryan Albee Professor of Medicine at Harvard Medical School (Boston, MA)

TRANSCRIPTION:

Jessica Bard: Hello everyone, and welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant 360, a multidisciplinary medical information network. Dr. Daniel Kuritzkes is here to speak with us today about a symposium in which he participated at ID Week 2022, titled Managing HIV Patients with Limited Treatment Options.

Dr Kuritzkes is the chief of the Division of Infectious Diseases at Brigham and Women's Hospital and Harriet Ryan Albee Professor of Medicine at Harvard Medical School in Boston, Massachusetts. Thank you for joining us today, Dr. Kuritzkes. Could you please provide us with an overview of this symposium?

Dr Daniel Kuritzkes: Yeah. This session is going to talk about, first of all, how do we define people who have limited treatment options? What are the new drugs available to help treat these individuals? What are some of the principles involved in putting together regimens for people, especially if they have multi-drug resistance? Then also to talk about some specific cases, and do some sort of case-based discussion around this challenge.

Jessica Bard: To get into a little bit more, how does one define a patient with limited treatment options?

Dr Daniel Kuritzkes: I think there are really two ways that we think about such people. One is most obvious, that is people who have been on many different regimens over time, typically, people who started antiretroviral therapy in the 1990s, and as a consequence, have developed drug resistance, and may have resistance to many, if not all the available agents.

Then trying to look for newer drugs and new ways of combining existing drugs to create a fully suppressive regimen in order to be able to preserve the immune function and keep people healthy. The other, sometimes less obvious, group of people that we consider to have limited treatment options are people who have difficulty either tolerating or sticking with regimens that are more commonly used.

This may be because people have specific toxicities from certain drugs, or because they have intolerance of certain drugs, symptoms that may emerge, whose options may be limited not because of viral resistance to the drugs, but because of more challenging factors, like a drug intolerance.

Jessica Bard: What should a clinician's approach be to managing a patient with HIV with limited treatment options, and how does one go about choosing a new regimen?

Dr Daniel Kuritzkes: Well, I think the first approach, of course, is to understand why does this individual have limited options? If in the case of somebody with treatment failure to, first of all, get as detailed as possible a history of prior drugs that have been used, and then to get resistance testing, and to make sure to obtain all previous resistance tests that might have been performed, in order to have a cumulative sense of what all of the existing resistance might be.

Resistance mutations may not be apparent in the current tests, but may be archived in the latent virus from prior exposure to older drugs. Those resistance mutations may not be evident in the current test. Then to get a sense of what drugs are the patient able to tolerate, what are the factors that make it difficult or easier to take certain drugs, or what are the patient's most important priorities in putting together a regimen, in order to have a better sense of what's the range of options for that patient?

Jessica Bard: What do you believe providers must be aware of when understanding the underlying processes that cause previous treatment failures?

Dr Daniel Kuritzkes: Treatment failure is typically driven by two factors, either inadequate potency of a treatment regimen. Fortunately, that is rarely the case nowadays that we have such good regimens, but it certainly contributed in a major way to treatment failure in the past. Second, challenges with adherence. Adherence may be suboptimal for a variety of reasons. It may be that there are subtle side effects of drugs that are making patients less willing to take their medication regularly. There may be lifestyle or other factors that impinge on a patient's ability to take their medication, especially if they have chaotic lives due to often psychiatric illness, or to substance use problems, or just to problems with housing and the like.

Understanding how those challenges may affect a patient's ability to adhere to therapy are important, and then helping to provide whatever social supports or other clinical support may be needed to address those problems in order to prove adherence to future regimens. Then of course, although not very common, a potential issue is to make sure that there aren't drug interactions that may be interfering with absorption, or accelerating the elimination of antiretroviral drugs, which could lead to suboptimal exposure to the drugs, which would then allow the ongoing virus replication and selection of drug resistance.

Those are the factors that people should really be aware of.

Jessica Bard: What would you say is next for research in the management of HIV patients with limited treatment options?

Dr Daniel Kuritzkes: Well, I think beyond the discovery and demonstration of the efficacy of novel agents, especially drugs with targeting novel parts of the viral life cycle, long-acting therapies are really the current big new horizon, improving treatment for all people with HIV, but particularly for those with limited monthly or every other month injectable therapy for people who don't have drug resistance.

People who have highly resistant viruses are often require very complicated regimens with multiple drugs taken several times a day. To the extent that some of those, the people have drug resistance because of adherence challenges, confronting them with a very complex regimen is the exact opposite of what we would like to do. Being able to have simpler, longer-acting regimens that deal with highly drug-resistant virus is really what's most needed now.

Jessica Bard: What would you say are the overall take-home messages from our conversation today and from your presentation at ID Week?

Dr Daniel Kuritzkes: First of all, that we do have new drugs that are available, and some of which are longer-acting and can be used to help treat people with limited treatment options, that these drugs can be used with high degree of success, especially when combined with other active agents, and that we need to continue working to optimize therapy for our patients, and continuing to search for better treatment for all patients, including those who are the most challenging to treat.

Jessica Bard: Well, thank you so much for joining us on the podcast today. We really appreciate your time.

Dr Daniel Kuritzkes: You're very welcome.