Before changing regimens in people whose viral load rises, try adherence counseling, researchers suggested in Clinical Infectious Diseases. Their post-hoc analysis of data from the ongoing phase III ADVANCE clinical trial in South Africa found that significant numbers of participants re-suppressed their virus after at least one virologic failure without switching treatment arms.
The study consisted of three arms: dolutegravir (DTG) plus emtricitabine/tenofovir alafenamide (FTC/TAF, Descovy), DTG plus emtricitabine/tenofovir disoproxil fumarate (FTC/TDF, Truvada), and efavirenz (EFV, Sustiva) plus FTC/TDF. (Disclosure: The study was supported by ViiV Healthcare, the manufacturer of dolutegravir, and Gilead Sciences, the manufacturer of tenofovir.)
Definitions of virologic failure varied depending on the study period: Among people who completed at least 12 weeks on their study regimen, the threshold was a viral load of 1,000 or more copies/mL; among those who completed at least 24 weeks, the threshold was 200 or more copies/mL; and among those who completed at least 48 weeks, the threshold was 50 or more copies/mL.
Following virologic failure, re-suppression was seen within the next three study visits among 67% of participants in the DTG+FTC/TDF arm and 64% of participants in the DTG+FTC/TAF arm, compared to 32% in the EFV+FTC/TDF arm.
These findings suggest that “virologic failure” may be an inadequate term, the study authors wrote. Noting that study participants with a detectable viral load received adherence counseling (in line with World Health Organization and local guidelines), they suggested such counseling as a first-line response for PLWH whose viral load increases after being suppressed on a regimen containing an integrase inhibitor. By helping a patient remain successfully on their current treatment, clinicians may help to limit pill burden and avoid more costly medications, they suggested.
Beyond adherence support, limited available HIV care funds could also be used for more direct adherence measurements, such as hair concentrations of antiretrovirals, the authors wrote. Beyond their low cost, such sampling might provide advance warning of issues before viral load goes up, they suggested.