From the Guidelines
Treatment for HIV with multiple drug resistance should involve using a combination of antiretroviral medications that the virus remains susceptible to, with a recommended approach of constructing a regimen with at least 2 fully active drugs from different classes. The choice of regimen depends on the patient's treatment history and resistance profile. For patients with virological failure after initial integrase strand transfer inhibitor (InSTI) regimens, options include dolutegravir plus 1 or 2 active nRTIs, or bictegravir/tenofovir alafenamide/emtricitabine 1.
Key Considerations
- For patients with a more complex treatment history, therapy with at least 2 fully active drugs from different antiretroviral drug classes is recommended 1.
- In the setting of multidrug-resistant HIV, newer agents like ibalizumab (an anti–CD4 monoclonal antibody) and fostemsavir (an attachment inhibitor) can be used when creating a salvage regimen for individuals with extremely limited treatment options 1.
- Fostemsavir had durable activity to 96 weeks in the setting of multidrug-resistant HIV with 60% of patients achieving an HIV RNA level below 40 copies/mL when combined with at least 1 fully active agent 1.
Treatment Options
- Dolutegravir (50mg twice daily) with at least 1 other active drug may be effective for virological failure after initial raltegravir or elvitegravir-based regimens in patients with integrase resistance mutations 1.
- A boosted PI regimen with 2 nRTIs (at least 1 fully active) is likely to be effective for virological failure after initial InSTI regimens 1.
- Ibalizumab or fostemsavir can be used when creating a salvage regimen for individuals with extremely limited treatment options, with evidence ratings of BIIa and AIa, respectively 1.
Monitoring and Adherence
- Regular viral load monitoring every 3-4 months is crucial to ensure the regimen remains effective.
- Adherence support is essential to prevent further resistance development and treatment failure.
From the FDA Drug Label
TROGARZO, in combination with other antiretroviral(s), is indicated for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in heavily treatment-experienced adults with multidrug resistant HIV-1 infection failing their current antiretroviral regimen. RUKOBIA, in combination with other antiretroviral(s), is indicated for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in heavily treatment-experienced adults with multidrug-resistant HIV-1 infection failing their current antiretroviral regimen due to resistance, intolerance, or safety considerations
The treatment options for multiple resistant gene in HIV include:
- Ibalizumab (IV), in combination with other antiretroviral(s), for heavily treatment-experienced adults with multidrug resistant HIV-1 infection failing their current antiretroviral regimen 2
- Fostemsavir (PO), in combination with other antiretroviral(s), for heavily treatment-experienced adults with multidrug-resistant HIV-1 infection failing their current antiretroviral regimen due to resistance, intolerance, or safety considerations 3
From the Research
Treatment Options for Multiple Resistant Gene in HIV
- The use of dual regimens, such as raltegravir plus darunavir/ritonavir, has been shown to maintain viral suppression in more than 90% of patients with multiple resistant gene in HIV 4.
- Genotypic resistance tests, such as cumulative genotypes, can interpret HIV drug resistance at a higher rate than last genotypes, and may be more accurate for selecting the next effective regimen of antiretroviral therapy 5.
- New antiretroviral agents, such as tipranavir, darunavir, etravirine, rilpivirine, maraviroc, and raltegravir, have resulted in marked progress towards the goal of being able to provide HIV-infected individuals with the drugs necessary to achieve decades of durable suppression of HIV without substantial toxicity 6.
- Nucleoside reverse transcriptase inhibitor (NRTI)-sparing regimens, such as maraviroc plus ritonavir-boosted darunavir, may be needed in patients with NRTI toxicity, and have been shown to be effective and safe in pretreated HIV-infected patients 7.
- Two-drug regimens, such as those recommended in treatment guidelines, can reduce lifetime exposure to antiretroviral drugs while maintaining the benefits of viral suppression, and have been shown to be virologically non-inferior to three-drug regimens in certain cases 8.
Key Considerations
- The choice of treatment regimen should be individualized based on the patient's specific needs and resistance profile.
- Genotypic resistance tests should be used to guide the selection of antiretroviral therapy.
- New antiretroviral agents and two-drug regimens offer increased options for individualized care.
- NRTI-sparing regimens may be necessary in patients with NRTI toxicity.
- The use of dual regimens, such as raltegravir plus darunavir/ritonavir, can maintain viral suppression in patients with multiple resistant gene in HIV.