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Applying HIV ASSIST

CME

Applying an HIV Care Decision-making Tool in Asia: HIV-ASSIST 

Physicians: maximum of 1.00 AMA PRA Category 1 Credit

Released: June 26, 2025

Expiration: June 25, 2026

Manish Bamrotiya
Manish Bamrotiya, MBBS, FHM
Tanyaporn Wansom
Tanyaporn Wansom, MD, PhD
CME/CE Information

Activity

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Course Completed

Patient Case 3: ART for a Treatment-Experienced Patient

Now, we are going to move on to the case of a 39-year-old man. He has been living with HIV for quite some time, having first engaged in treatment in 2012. Currently he is receiving combination elvitegravir (EVG)/COBI/TAF/FTC. Like many of my patients in Asia, he has been moving around a lot, most likely for work. He has also experienced periods of housing insecurity.

Prior to this encounter, this person had not been seen for 9 months, although he was still able to pick up his ART.

As of this visit, his laboratory values are as follows:

  • CD4+ cell count: 85 cells/mm3
  • HIV-1 RNA: 31,000 copies/mL
  • HIV-1 genotype: M184V and E92Q mutations
  • CBC: normal
  • Comprehensive metabolic panel: normal
  • Liver and renal function: normal
  • No hepatitis B or hepatitis C confection
  • No comedications
  • HLA-B*5701 status: negative

ART and Genotype History
As this person is treatment experienced, next we will review his ART history and genotype testing. He was diagnosed in 2012 and was prescribed a regimen consisting of TDF/FTC/EFV, with EFV being a common first-line ART drug in Asia. At that time, his HIV-1 RNA was suppressed.

Unfortunately, from late 2012-2014, he discontinued ART, possibly because he moved for work in another region and did not engage in HIV care there. He returned to care later in 2014, when he began receiving his most current regimen of EVG/COBI/TDF/FTC.

During 2014-2015, he had his HIV-1 RNA measured on 4 occasions. It was undetectable the first time it was measured. Then he may have had a blip, with an HIV-1 RNA of 140 copies/mL. At the third time that it was measured, it was a little bit higher, at 287 copies/mL. Finally, his HIV-1 RNA was undetectable again at the fourth test.

However he went off ART completely again, between mid-2015 to mid-2017. Later in 2017, he returned to that same regimen and once more attained viral suppression.

His genotype was assessed in 2014 and 2017 and no reverse transcriptase or proteasome inhibitor mutations were detected at either test. In 2017, testing for integrase strand inhibitor mutations was included, with none detected.

However, in his most recent genotype, he was found to have a reverse transcriptase mutation, M184V, and an integrase strand inhibitor mutation, E92Q.

Next, let us go over 3 factors that will play a major role in determining an appropriate ART regimen for this person: His current ART regimen, his RAMs, and his ART adherence. Later I will demonstrate how HIV-ASSIST can help account for these factors, but let us review them first.

Current ART
His current ART regimen, EVG/COBI/TAF/FTC, is a single tablet and is an integrase strand transfer inhibitor (INSTI)–based regimen that was approved by the FDA in the United States in 2015. It is a newer formulation of his previous regimen, EVG/COBI/TDF/FTC, which updates TDF with TAF.

One potential issue with his current regimen is that it contains COBI, a pharmacologic booster associated with many drug–drug interactions and gastrointestinal adverse effects. Because of these gastrointestinal adverse effects, this regimen is recommended to be taken with food. Another potential concern with this regimen is that EVG has a relatively low barrier to resistance compared with other INSTIs, including DTG.

RAMs
Next, we delve into the RAMs that we see in this patient's genotype. M184V is a mutation in the HIV reverse transcriptase gene that reduces susceptibility to 3TC and FTC more than 100-fold. This RAM is often associated with intermittent ART adherence, suboptimal viral suppression, or increased time since HIV diagnosis.

However, despite reducing susceptibility to 3TC and FTC, M184V increases susceptibility to tenofovir. This is a key point for selection of a new ART regimen.

This patient also has E92Q, one of the most common RAMs observed among patients receiving EVG. As mentioned, EVG has a low barrier to resistance. The E92Q mutation reduces susceptibility to EVG approximately 30-fold. 

So, how can we choose a new regimen for this treatment-experienced patient? The first thing we should remember is that the new regimen should include 2, but preferably 3 fully active agents.

Patient Factors and Preferences
Next, we should consider patient factors and preferences that affect ART adherence. This patient showed intermittent adherence in the past, with viral blips that potentially suggested he was moving toward resistance. Finally, considerations of ART simplification, tolerability, and drug–drug or drug–food interactions can be important, especially with people who are working or experiencing housing instability. 

Which ART regimen would you recommend in this patient?

Video 3: Demonstration

Patient Case 3: Discussion

In all, there are advantages and disadvantages to each of the suggested ART regimens, but the availability and cost will definitely be major factors in selecting the right regimen for this patient. 

In this case, regimens containing boosted DRV are ranked as more favorable, with the single-tablet regimen of DRV/COBI/TAF/FTC ranked as most favorable.

For this case, other regimens containing boosted DRV are also strongly recommended. There might be an increase in number of total pills, but the tradeoff of availability is crucial for this patient’s adherence during times when moving around or experiencing housing instability. Furthermore, even though the number of pills may increase with a new regimen, dosing is still once a day.

HIV-ASSIST enables us to quickly and easily identify suitable ART regimens, with detailed information on regional drug availability at our fingertips. This case illustrates the benefits of using HIV-ASSIST for treatment-experienced individuals who have more considerations than those just initiating treatment.

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