IS there a simpler regimen?

Question

I'm taking the following: Prezista 600 mg 2x/day, Norvir 100mg 2x/day, Tivicay 50mg 2x/day, Descovy 1x/day, and Intelence 200 mg 2x/day.

This seems like a lot of medicine! Especially b/c the only drug I'm mostly resistant to in this combo is the FTC (M184V). Why do I need so many active drugs?

I would really like to cut out the protease inhibitors. They mess up my other meds, make methadone not work as well, and make it impossible to take birth control pills that I really need.

My doctor said if I didn't want the protease inhibitors, I would have to switch to rilpivirine. I'm close to 100% compliant on pills, but I don't think it would be easy to eat that much at the same time every day.

Is there any other way to simplify things, maybe with the new Biktarvy or Juluca? Like Juluca in the morning, Biktarvy at night, or something like that?

I would like to either cut the protease inhibitors entirely and/or come up with a regimen that's only once per day. I know so many other people who only have to take dolutegravir or Prezista once a day and I don't understand why I'm taking them twice.

The meds I'm sensitive to on genotype are: nukes: tenofovir (partly sensitive) NRTI: etravirine, rilpivirine PIs: atazanavir, darunavir ISI: elvitegravir, dolutegravir (wasn't tested for bictegravir)

Thank you very much for your advice.

Answer

Hello and thanks for posting.

You indeed have a rather complex regimen. Selecting a antiretroviral treatment (ART) when one has drug-resistant HIV requires (preferably) knowledge of the drug resistance pattern, or at least, the previous treatment history. The goal is to create a regimen that has at least two, and no more than three active drugs in the regimen.

For example, if your viral load is suppressed and your virus only has the M184V drug resistance mutation (conferring resistance to 3TC and FTC, but increasing sensitivity to other drugs, like tenofovir and AZT), a simple regimen of Tivicay (once-daily is adequate unless your virus has certain integrase inhibitor resistance mutations) with Descovy (tenofovir alafenamide/FTC) is likely adequate (and a recent large study showed this superior to a boosted protease inhibitor regimen containing lopinavir (Kaletra).

There are some other alternatives to discuss with your provider: If your virus also doesn't have protease inhibitor resistance, simplifying your Prezista to once daily (either with Norvir, or in the co-formulated Prezcobix) could be considered.

There's also a possibility (if your virus doesn't harbor NNRTI resistance) to use the dolutegravir (Tivicay)+ rilpivirine (Edurant) coformuation called Juluca- this isn't approved for use in patients with drug resistant virus, per se, but could be used with Descovy to provide three active drugs (without the use of your Prezista, Norvir and Intelence).

So, yes, there are some strategies. I hope that's helpful, BY