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.

But with broad NRTI resistance, I confess I'm kind of worried about changing to a drug (RPV) that is arguably less potent than what she's on (EFV).

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?

Answer: Yes.

What would you do in this case?

  1. Change to Complera (TDF/FTC/RPV).
  2. Tell her she must continue the Atripla (TDF/FTC/EFV) -- let her work out the finances.
  3. Fight with the insurance company on your patient's behalf, threatening to publicize the case widely in the papers, Facebook, Twitter, etc.

[Editor's note: You can vote on this poll and view results by visiting the original blog post.]

Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.