Specialties & Topics
- Arthritis/Rheumatic Disease
- Breast Cancer
- GERD/Peptic Ulcers
An ongoing dialogue on HIV/AIDS, infectious diseases,
November 2nd, 2012
Antiretroviral Rounds: Resistance on Two Fronts
Got this challenging curbside consult from a colleague, and it has a interesting wrinkle:
I have a longstanding patient with HIV who had many failed regimens in the 1990’s with resultant following mutations on a genotype done in 2003:
NRTI (M184V, Q151M mutations); PI (A71, I54V, K20M, L10I, L90M, V82A mutations); no NNRTI resistance.
She has been undetectable since then on TDF/FTC/EFV; CD4 of >700 and never a low nadir.
Now, however, her insurance is making her pay tremendous copays of ~2K/month and she can’t afford it. She makes just enough that she doesn’t qualify for any drug assistance programs — she’s been to every advocacy group in the area, and is told no assistance is available.
Somehow, Complera is a tier 3 (favorable), while Atripla and many of the other drugs she is not resistant to is a tier 5.
Should I switch to Complera? Any other ideas? Other less expensive meds are abacavir/3TC, Kaletra, plus a bunch of others we never use anymore.
Two thoughts on this case, one medical, one much less so.
First, the medical part — my gut feeling here is that she’d probably be fine on TDF/FTC/RPV, given the duration of virologic suppression. These patients with long-term undetectable HIV RNA can generally make lots of changes to their regimens (within reason), and they maintain control of the virus. And the TDF and RPV both would be active.
So I’m undecided.
Now the non-medical part — isn’t it ridiculous that someone whose treatment has been working well for nearly a decade must now consider switching based on 1) a higher “tier” of costs passed along by the mega-million dollar insurance company, who probably earn that much profit in a nanosecond, and 2) her not meeting criteria for patient assistance?
Paul E. Sax, MD
Learn more about HIV and ID Observations.
- ID Cartoon Caption Contest (122)
- Mystifying Abbreviations on Daily Medical Rounds (46)
- Should Doctors Still Be Allowed to Wear White Coats? You Decide (43)
- Are ID Doctors the Worst Dressed Specialists? (39)
- A Ridiculously Long Post: How EHRs Expose Unspoken Hierarchies Within Medicine — Or Maybe Are Just Bad (35)
Subscribe to HIV and ID Observations via Email
- Low Risk for Zika Virus Spread by Olympics Attendees (FREE)
- Third Generation Cephalosporin-Resistant Enterobacteriaceae Carriage in Germany
- Hand, Foot, and Mouth Disease — Not Just for Kids
- Rural Outbreak of HIV in Injection-Drug Users
- Support for a Genetic Predisposition to Staphylococcus aureus Bacteremia
Physician's First WatchToday's breaking medical news
- Abacavir AIDS aids clinical care antibiotics antiretroviral therapy ART atazanavir baseball CDC C diff CROI cure darunavir dolutegravir efavirenz elvitegravir etravirine FDA HCV hepatitis C HIV HIV testing ID Learning Unit Infectious Diseases influenza Link-o-Rama lyme disease Massachusetts MRSA Patient Care PEP Policy PrEP prevention primary care raltegravir Really Rapid Review Research resistance Retrovirus Conference rilpivirine sofosbuvir TDF/FTC tenofovir vaccination