How to manage a patient with low CD4 count and percentage on Biktarvy (bictegravir, emtricitabine, and tenofovir alafenamide) therapy?

Management of Patient with Low CD4 Count on Biktarvy

Patients with CD4 counts <200 cells/μL on effective antiretroviral therapy (ART) should continue their current Biktarvy regimen while initiating Pneumocystis jirovecii pneumonia (PJP) prophylaxis with trimethoprim-sulfamethoxazole. 1

Assessment of Current Status

The patient presents with:

• CD4 absolute count: 210 cells/μL (below normal range)
• CD4 percentage: 17.82% (below normal range)
• CD8 absolute count: 604 cells/μL (normal)
• CD8 percentage: 51.30% (above upper limit)
• CD4/CD8 ratio: 0.35 (low)
• Absolute lymphocyte count: 1178 cells/μL (normal)
• Currently on Biktarvy (bictegravir 50 mg, emtricitabine 200 mg, tenofovir alafenamide 25 mg)

Management Recommendations

1. Continue Current ART Regimen

• Maintain Biktarvy therapy as it is a recommended first-line regimen with high efficacy 2
• Biktarvy has demonstrated high rates of viral suppression in clinical trials (>90% at 48 weeks) 3
• The patient's low CD4 count does not warrant changing ART if viral suppression is maintained 2

2. Evaluate for Virologic Suppression

• Immediately check HIV viral load to confirm viral suppression 2
• If viral load is <50 copies/mL, continue current regimen
• If viral load is detectable (>50 copies/mL), assess adherence and potential drug interactions 2

3. Opportunistic Infection Prophylaxis

• Initiate PJP prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) one double-strength tablet daily 1
• Consider toxoplasmosis prophylaxis if Toxoplasma IgG positive (TMP-SMX provides dual coverage) 1
• Obtain dilated retinal examination to rule out CMV retinitis given the low CD4 count 1

4. Additional Workup

• Evaluate for other causes of immunosuppression beyond HIV:
  • Concurrent infections (tuberculosis, histoplasmosis)
  • Malignancy
  • Medication effects
  • Malnutrition

5. Monitoring Plan

• Monitor CD4 count and HIV viral load more frequently:
  • Viral load testing monthly for the first 3 months, then every 3 months 1
  • CD4 count every 3-4 months 2
• Continue PJP prophylaxis until CD4 count increases to >200 cells/μL for at least 3-6 months on ART 1

Important Considerations

Adherence Assessment

• Verify medication adherence as this is the most common cause of treatment failure 2
• Assess for potential drug-drug interactions that might affect Biktarvy efficacy
• Ensure proper administration (Biktarvy should not be crushed or split as this may affect bioavailability) 4

Immune Reconstitution

• CD4 recovery may be slow in some patients despite viral suppression
• Immune reconstitution inflammatory syndrome (IRIS) is possible if viral load was recently suppressed

When to Consider Regimen Change

Biktarvy should only be changed if:

• Virologic failure is confirmed (HIV RNA >200 copies/mL) 2
• Significant drug-drug interactions are identified
• Serious adverse effects occur

Pitfalls to Avoid

1. Don't change ART regimen based solely on CD4 count if viral suppression is maintained and adherence is good 2

2. Don't miss opportunistic infection prophylaxis - PJP prophylaxis is essential with CD4 <200 cells/μL 1

3. Don't overlook adherence issues - verify that the patient is taking medication correctly before considering regimen changes 2

4. Don't attribute all symptoms to HIV - evaluate for concurrent conditions that may contribute to immunosuppression

5. Don't delay additional testing - obtain viral load immediately to guide management decisions

Biktarvy remains an excellent regimen for this patient provided viral suppression is confirmed. The focus should be on prophylaxis for opportunistic infections, close monitoring, and addressing any adherence issues rather than changing the ART regimen.