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Author Topic: New HIV drugs with a higher resistance risk should be classed as inferior  (Read 5512 times)

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Offline Jim Allen

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NOTE:
I am adding a note to this thread, given the direction of the conversation. Please keep in mind this is just us speaking our thoughts and fears, irrational or not, freely as PLHIV.

There were some treatment failures in the studies and clinical follow-ups under dual therapy. (Links in the thread) Still, given the numbers, it statistically seems to be relatively rare, so there is no need to panic if you are reading this thread and on dual therapy or considering it.

Just watch your adherence levels as always and talk to your doctor if you are concerned for reassurance next time you are due.   



Original post:

I felt these things were known and relatively obvious, although I suppose not everyone reads drug studies in full and consults their doctors on potential risks & drawbacks.

https://www.aidsmap.com/news/dec-2023/new-hiv-drugs-should-be-classed-inferior-if-they-carry-higher-risk-resistance

Quote
New antiretroviral regimens should be considered inferior to older ones unless trials can demonstrate that their failure doesn’t lead to more drug resistance than standard treatment, Italian researchers argue in Lancet HIV.

Italian physicians Diego Ripamonti and Mauricio Zazzi draw attention to the concerning resistance patterns that emerged in people who switched treatment and experienced viral rebound in several studies in which rilpivirine was combined with an integrase inhibitor.

In the SWORD studies of switching from three-drug treatment to dolutegravir and rilpivirine, 11 people experienced virological rebound. Six people who switched to dolutegravir and rilpivirine developed resistance to rilpivirine. No one who experienced viral rebound on three-drug treatment developed major resistance mutations.

In the LATTE study, participants received oral cabotegravir plus two nucleoside reverse transcriptase inhibitors (NRTIs) for 24 weeks before switching to oral cabotegravir and rilpivirine if they suppressed viral load. Eight people experienced viral rebound and six developed drug resistance, including three cases of integrase inhibitor resistance. Again, no one who experienced viral rebound on the three-drug regimen developed resistance.

The ATLAS-2M study evaluated monthly or two-monthly injections of cabotegravir and rilpivirine in virally suppressed people who had either been taking three-drug treatment or monthly injections of cabotegravir and rilpivirine. Although the numbers were low, more people in the two-monthly injections group experienced virological failure (approximately one in forty) than in the monthly injections group (one in two hundred). Ten participants developed resistance to cabotegravir and eight to rilpivirine.

“Given the current availability of oral high genetic barrier regimens, we believe the rate of treatment-emergent resistance should be incorporated in an updated definition of HIV therapy success,” say the Italian physicians.

“Modern treatment options should be ranked according to the risk of failure with resistance [… and] patients should be informed about the potential (although minimal) risk of resistance to integrase inhibitors.”

They note that British HIV Association guidelines recommend that people with HIV who are considering a switch to injectable cabotegravir and rilpivirine should be informed about the risk of resistance to both drugs.
« Last Edit: December 29, 2023, 06:18:38 am by Jim Allen »
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Offline leatherman

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #1 on: December 27, 2023, 10:30:19 am »
I felt these things were known and relatively obvious
two-drug regimens might not be as "effective" as three-drug regimens? Who would've thunk it? :)
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Offline kentfrat1783

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #2 on: December 27, 2023, 07:38:28 pm »
I rember when I was going to Cleveland Clinic and they stated that it would not be good to go a two pill regiment. I never asked but I was thinking there had to be a good reason for the three pill regiment and it works for me. 

Unless I have an issue or my insurance says I need to change I don't see a reason to change. My main fear is resistance issues. 

But on a personal opinion, I think too many poeple change just becuase they see it on TV and want the "new" pill.   They need to remember it isn't a new phone or a new pair of glasses. 
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Offline leatherman

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #3 on: December 27, 2023, 08:53:08 pm »
I never asked but I was thinking there had to be a good reason for the three pill regiment and it works for me.   
there are several steps in how HIV infects a tcell. HIV meds were developed to stop this process. Some meds stop HIV from attaching to the tcell; some stop HIV from fusing into the cell. Other meds stop HIV from integrating into the cell or inhibit the reverse transcriptase inside the cell. Other meds stop HIV from using the tcells as mini HIV factories.

What science learned was that HIV was a tricky virus. Stopping one action of the infection wouldn't stop the other ways and often let HIV learn how to adapt to the med. (that was the late 80s) Two meds seemed to work better but resistance issues eventually won out. (the early 90s) Continuing to develop all the types of meds, finally allowed HIV to be controlled when three methods of it's replication were interrupted or disallowed. (HAART was developed in the mid 90s). And that's why most anti-HIV medication regimens contain a combination of 3 meds either as separate meds or a combination medication.
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Offline Jim Allen

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #4 on: December 28, 2023, 09:35:45 am »
two-drug regimens might not be as "effective" as three-drug regimens? Who would've thunk it? :)

 ;D lol.

Quote
Stopping one action of the infection wouldn't stop the other ways and often let HIV learn how to adapt to the med. (that was the late 80s) Two meds seemed to work better but resistance issues eventually won out. (the early 90s) Continuing to develop all the types of meds, finally allowed HIV to be controlled when three methods of it's replication were interrupted or disallowed. (HAART was developed in the mid 90s). And that's why most anti-HIV medication regimens contain a combination of 3 meds either as separate meds or a combination medication.

Yeah, this isn't new. The results today with dual therapy are better than previous attempts, as the meds are far better. Resistance levels are higher, and bioavailability is better. The same goes for monotherapy. However, monotherapy is still a total shitshow.

I do have a theory, not related to the meds themselves but our behaviour/habits that could be partly to blame, although it's just a theory, no facts, just thinking out loud.

In the real world, some people take their meds only four or five days a week (3) and plenty of us take them every day but not necessarily at the same time.  Thankfully, most HIV treatment combinations from 2000 to 2020 are very forgiving. The old 95% gold standard rule from the 1990s went out of the window somewhat, and I've even heard doctors saying take the meds once a day, and the when isn't that important.  1)

With Dual therapy (2) I suspect some of the issues seen are because of these habits that have crept in over the years, and a more strict level of adherence might generally be needed, like back in the late 90s, with the 95% rule. Again, this is just me thinking out loud; no evidence to confirm that it's a potential cause.

I have no idea what the story is with injectables. It could be just less of a barrier, plain inferior without user error, but I will say it's not news; I still think it's a good alternative option for people who need it or have barriers to daily ART.



1)
https://forums.poz.com/index.php?topic=73003.0
Newer HIV Regimens May Require Less Strict Adherence (Meds used in 2014-2016)

2)
https://forums.poz.com/index.php?topic=77539.0
(Monotherapy & Dual therapy) Dolutegravir resistance is rare, but some risk factors can up the odds.

3)
Caution over French study only taking ART 4 days a week
http://i-base.info/htb/36517

FOTO: https://www.poz.com/article/hiv-efavirenz-intermittent-16959-8019

Thread:
Every Other Day: https://forums.poz.com/index.php?topic=72189.msg

Thread: Fours days a week
https://forums.poz.com/index.php?topic=72799.msg
« Last Edit: December 28, 2023, 09:46:48 am by Jim Allen »
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Offline Jim Allen

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #5 on: December 28, 2023, 10:36:02 am »
Anyhow, I am sure more in-depth insights will be gained over the years ahead as plenty of people recently switched to dual therapy or injectables.
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Offline numbersguy82

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #6 on: December 28, 2023, 05:45:00 pm »
Wow this was all very insightful. To be honest, I think you are on to something there Jim. I think our habits and long term laziness/comfort setting in are the biggest challenges to staying adherent and healthy with our pill taking.

There was a time back in 2010 when I took 3 separate pills and knew each one’s name and what role they played. Fast forward to today, and I just googled if Biktarvy had two medicines or three.

The upside is I no longer think about my diagnosis. If you’d have told me upon diagnosis that there’d come a time when I popped one pill and largely never thought about hiv, I wouldn’t have believed you. Now the pendulum probably needs to swing back a little bit… I’m not getting any younger and well my health should be on my mind.
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Offline daveR

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #7 on: December 29, 2023, 04:15:01 am »
I discussed the possibility of changing to a two dug regime 12 months ago with my Dr by dropping Abacavir form my regime. Her advice then was to wait and see a bit longer. Looks like she was correct in doing that.

Offline Jim Allen

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #8 on: December 29, 2023, 05:53:00 am »
I discussed the possibility of changing to a two dug regime 12 months ago with my Dr by dropping Abacavir form my regime. Her advice then was to wait and see a bit longer. Looks like she was correct in doing that.

My appointments are the opposite; they keep trying to switch me to Dovato, and I keep reminding them that I am not doing that. 

I do understand wanting to drop ABC (Abacavir) 1); I was and still am not overly worried about it. The issue with ABC has been known for years, and I worked it out as a bit of a storm in a teacup years ago; however, as I am older 2) and over the years, meds have improved, I think the time has come to drop ABC, but not for Dovato.

My issue is I want to remain on HAART, not injectables or Dual therapy. However, I don't want anything to do with TAF or TDF, and the point of switching is to drop ABC. It leaves me with very few available options... :(

1)

Experts recommend statins for all people with HIV aged 40+
https://forums.poz.com/index.php?topic=66320.150

a strong association between recent ABC use and risk of CVD remains
N.J. Jaschinski1, on behalf of the RESPOND study group
1University of Copenhagen, Rigshospitalet, CHIP, Copenhagen, Denmark
https://eacs2021.abstractserver.com/program/#/details/presentations/243
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Offline Jim Allen

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #9 on: December 29, 2023, 06:14:52 am »
Wow this was all very insightful. To be honest, I think you are on to something there Jim. I think our habits and long term laziness/comfort setting in are the biggest challenges to staying adherent and healthy with our pill taking.

There was a time back in 2010 when I took 3 separate pills and knew each one’s name and what role they played. Fast forward to today, and I just googled if Biktarvy had two medicines or three.

The upside is I no longer think about my diagnosis. If you’d have told me upon diagnosis that there’d come a time when I popped one pill and largely never thought about hiv, I wouldn’t have believed you. Now the pendulum probably needs to swing back a little bit… I’m not getting any younger and well my health should be on my mind.

100% agree. It is part of the testament to how good HIV treatment has become over the years, and I truly suspect that a return to more strict adherence is needed when switching from HAART to Dual therapy, again I have no evidence of this; it is just speculation based on some data from the mid 2010s and my limited observations under PLHIV, and how lacks we have become and now this low failure rate of dual therapy.

Although, I did miss this one from October:

Intermittent dosing on HIV dual therapy leads to a higher rate of treatment failure
https://www.aidsmap.com/news/oct-2023/intermittent-dosing-hiv-dual-therapy-leads-higher-rate-treatment-failure
« Last Edit: January 01, 2024, 09:34:13 am by Jim Allen »
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Offline Dogman

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #10 on: January 26, 2024, 12:15:15 pm »
The upside is I no longer think about my diagnosis.
I hope I can get to this point. I've taken a dive recently back into it invading my thoughts constantly. No valid or logical reason.

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #11 on: January 26, 2024, 12:24:35 pm »
I hope I can get to this point. I've taken a dive recently back into it invading my thoughts constantly. No valid or logical reason.

Sorry to hear that. We are here for you, hugs.
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Offline numbersguy82

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #12 on: January 26, 2024, 02:53:32 pm »

Intermittent dosing on HIV dual therapy leads to a higher rate of treatment failure
https://www.aidsmap.com/news/oct-2023/intermittent-dosing-hiv-dual-therapy-leads-higher-rate-treatment-failure

Not for nothing but I’d be too afraid to sign up for a study like this. We are so conditioned not to miss doses and to ensure daily dosing occurs. I guess there isn’t progress without some measurable risk…
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Offline Jim Allen

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #13 on: January 27, 2024, 02:15:55 am »
Not for nothing but I’d be too afraid to sign up for a study like this.

They are very brave or ... https://www.youtube.com/watch?v=yycFr3YeKFM
Anyhow, you will not catch me pissing about with dosing.
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Offline CircularNatural

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #14 on: February 20, 2024, 04:50:09 pm »
You guys are giving me a bit of a creeps with this chat, LOL.
I´m poz since 2021 and sort of chose to go for Dovato (dol + 3tc).
Have been undetectable ever since but of course the fear of potential resistance comes and goes. I´m quite obssesive in relation to adherence, though, which helps a lot.
I hope they keep on making progress and advances on long term safety in this matters, though.
So far, I´ve always understood that so long you keep the virus at bay there shouldnt be a resistance, unless you adhere poorly. In that sense, I hope that if I keep on being orderly regards my Dovato daily intake, I shouldn´t have a problem.
Hope that works that way for all of us.
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Offline leatherman

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #15 on: February 20, 2024, 04:59:15 pm »
So far, I´ve always understood that so long you keep the virus at bay there shouldnt be a resistance, unless you adhere poorly.
resistance happens when HIV are taken haphazardly.

When you take ARVs, the meds get into your system and stay there for a certain amount of time before leaving your system. We take meds daily to keep that level up enough that HIV doesn't learn to resist the medications. Skipping a dose won't do it. Even skipping a couple. However if you take the meds haphazardly - like 2 days on, 4 days off, 3 days on, 1 off, 2 days on, 3 off - and the levels of meds keeps dipping too low, HIV can mutate to resist medications.

As long as you stay at 95% adherence and above, resistance will never happen and theoretically you can stay on the same meds forever.
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Offline Jim Allen

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #16 on: February 20, 2024, 05:05:32 pm »
if you take the meds haphazardly - like 2 days on, 4 days off, 3 days on, 1 off, 2 days on, 3 off - and the levels of meds keeps dipping too low, HIV can mutate to resist medications.

As long as you stay at 95% adherence and above, resistance will never happen and theoretically you can stay on the same meds forever.

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Offline Jim Allen

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #17 on: February 20, 2024, 05:08:59 pm »
You guys are giving me a bit of a creeps with this chat, LOL.

I'm not supprised. That why I added a note in the first post to avoid freaking people out
Although, this thread is nowhere near as bad as the conversations during the monthly meetings
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Offline wardp

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Re: New HIV drugs with a higher resistance risk should be classed as inferior
« Reply #18 on: February 27, 2024, 09:07:39 pm »
6yrs on lamidivuine and neveripine.i rarely miss a dose maybe once or twice a year. All good .touch wood.
Diagd 20,July 2017. Cd4 289, 21% vld .3,462  atripla 4/8/17, 5/10/17 cd4 384 21%, ud.  complera 4/11/2017 switched to stribild 15/11/17. Switched to truvada efavirence 200mgx2 14 Dec 2017, 2 Feb 2018, uD cd4  466, 25%  CD 8 ,595, 32%..1 may 2018
switched  to instgra truvada.7th june switched to truvada  nevirapine stavudine. .21 june switched to truvada nevirapine. X 2 a day...9 aug 2018 ud. 2n Nov 2018 CD 4. 455..22.70% 13th Nov switched  to lamivir and nevirapine  due to kidney issues...jan 10,2019 UD..may 13 2019 ud  cd4 482 28% 14th nov 2019 ud. Cd4 414 .27% cd8 444 29%,may 16 2020,ud ,cd4 741"19.62. Dec 2020.ud.jan21 cd4 453. 25.7% 5/6/21.UD. cd4 621;{27.21%}19/10/21 UD.cd4 420; 28%.apr 19;2022 UD cd4 455' 26%.oct 22,UD, cd4 381,27% 10/4.23 UD CD4 462 29%.2/10/23 cd4 378,28%cd 533 26%

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Posting in this thread as its directly related, insightful read.

Aidsmap article - Rosalie Hayes - 30 April 2024. https://www.aidsmap.com/news/apr-2024/caution-advised-when-prescribing-long-acting-injectable-cabotegravir-and-rilpivirine

In Brief:

Quote

HIV clinicians have issued a note of caution regarding long-acting injectable cabotegravir and rilpivirine in a recent commentary in AIDS. Dr Diego Ripamonti of the Papa Giovanni XXIII hospital in Bergamo and colleagues from the universities of Milan and Siena highlight that people with long treatment histories in particular may not be good candidates for the treatment, due to the substantial risk of developing resistance to the drugs should the treatment fail.

In clinical trials, injectable cabotegravir and rilpivirine was found to be similarly effective to daily pills in suppressing HIV to undetectable levels.

However, in the small minority of participants for whom injectable treatment didn’t work (around 1% (26/2313) of participants in the five main clinical trials), there was a high rate of emergent resistance to integrase inhibitors. Having resistance to these drug types is a big problem for patients as it greatly limits the types of HIV treatment that will effectively suppress their HIV.

The authors point out that while taking pills 80–85% of the time is enough to avoid treatment failure with most modern HIV treatments, some of those who developed drug resistance to injectable cabotegravir and rilpivirine in the trials had perfect adherence.

They also highlight that the level of emergent resistance in injectable cabotegravir and rilpivirine trials is higher than any other ‘simplified’ drug regimen, even including dolutegravir monotherapy – a drug regimen which has been criticised by many experts and is not recommended for use.



Quote
The table includes data on ‘emergent resistance’ – this means that resistance to integrase inhibitors (like cabotegravir) or NNRTIs (like rilpivirine) was not detected in blood samples taken before the participants started injectable treatment and was detected in blood samples after the participants started injectable treatment.

The table shows that the number of people who experienced confirmed virological failure (column in blue) was very small, Of those with confirmed virological failure (column in purple), the rates of emergent resistance were high, ranging from 33.3%-100%.

Consequently, the authors make the following recommendations:

  • Factors that put people at risk of developing drug resistance should be thoroughly investigated before prescribing injectable cabotegravir and rilpivirine. In particular, clinicians should aim to use DNA resistance testing to detect archived mutations, although this test is not always available.
  • Doctors should be cautious when prescribing long-acting injectable cabotegravir and rilpivirine to patients with long and/or complex treatment histories. In addition, people with low CD4 cell counts or previous experience of AIDS were excluded from clinical trials, and might also be at risk of treatment failure.
  • Before switching a patient to injectable cabotegravir and rilpivirine, clinicians should proactively identify their remaining treatment options should they experience treatment failure and develop resistance to both drugs.

“As appealing as this long-acting option may appear, both clinicians and people with HIV should be aware of the associated risks, carefully weighing all baseline factors and planning the appropriate exit strategy in the event of failure,” conclude Dr Ripamonti and colleagues.
« Last Edit: May 04, 2024, 08:37:32 am by Jim Allen »
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