Ryan Haumschild, PharmD, MS, MBA: I think now that we have that clinical background and treatment history, I’m curious from my other colleagues, maybe we’ll start with you, Mr Driffin, what do you think the economic and social burden is of multidrug resistant [MDR] HIV [human immunodeficiency virus] in this patient population?

Daniel Driffin, BS, MPH: I think that’s a great question. Instantly, I think about the financial burdens multidrug resistance can place on a person, especially those people living with HIV. When I think as Dr Sension was saying, oftentimes these may be patients who have been long-term survivors, living with the virus for 15, 20, 30 years. If we’re factoring that in, it’s safe to assume they are also living on limited incomes, so food, employment, and housing come into the conversation. Outside of financial things, I think about the mental health aspects. Not being able to take a single-tablet regimen, or to take the latest HIV drugs we may see on television now, could cause stigma, shame, fear, or even denial. Those are some of the things I think about instantly.

Ryan Haumschild, PharmD, MS, MBA: Excellent, thank you. I know there’s the vision and economic burden from the patient’s perspective, and that’s so important to keep in mind, and we should always think of that front-facing. But I do know that payers are also concerned. Dr Lopes, being a medical director in the payer realm, what are your thoughts on the economic and social burden from a payer’s perspective around MDR HIV?

Maria Lopes, MD, MS: Absolutely. The first thing that comes to mind as a payer is, what treatment options exist? There’s a cost of failure when members and patients aren’t virally suppressed. They end up in the ED [emergency department], they end up in the hospital. As you age you also have comorbidities, listening to Dr Sension talk about the drug-drug interactions, and things get more complex as you have to add more regimens. On top of the standard of care, if you now have to add regimens, how complicated is the adherence going to be, and how do we facilitate that? We obviously think about the total cost of care. We also think about barriers and social determinants of health as a barrier. The direct cost is that if you’re not virally suppressed you’re going to soon have resistance. Then there’s also the transmission issue from a public health perspective, with the spread of disease and transmission as major issues.

Ryan Haumschild, PharmD, MS, MBA: You bring up some great themes. You think about the total cost of care and transmission, but really the burden to the patient. Financially, if they have to keep paying for therapies, and they’re not getting a therapeutic or viral suppression, that’s putting them through additional discomfort, maybe putting them through adherence challenges, and ultimately not getting to that right kind of spectrum. As a payer, how do we make sure we’re approving the right therapies that provide that therapeutic benefit? It may be a little more costly, but if they can get patients there, it’s definitely something to consider, especially in the more difficult-to-treat patient population.

Dr Sension, I want to come back to you because I know you have a lot of experience treating different patients, and you’ve been a pioneer in the medical field as we provide new innovative therapies. We know that patients with MDR HIV tend to be a very vulnerable population. If you could, discuss some of the reasons behind this as well, as potential comorbidities or illnesses that may be more prevalent in this population because of their MDR HIV.

Michael Sension, MD: If somebody is truly not virologically suppressed, and they’re viremic and having ongoing immunosuppression, they may very well develop comorbidities, and it could be directly related to their immunosuppression. As people age with HIV, they develop comorbidities as well, which further complicates the medication regimens that they have to be on. What I’ve seen in the evolution of HIV treatment through my career, I want to go back to the definition of resistance, of how we got there in the first place, and that is having subtherapeutic levels of a drug in the presence of a replicating virus. What leads to subtherapeutic levels of a drug? Well, missed doses for whatever reason. What lends itself to greater adherence is simplicity. We’ve gone from multiple tablets multiple times a day, and there was a time when HIV treatment was referred to as a cocktail. We would never refer to a 1-pill-a-day treatment as a cocktail now, but we did 25 years ago because it was, “Take 6 of these, 4 of these, 3 of these, and take them 3 times a day.” That was a big handful of medicine. It was inherently flawed in that people would miss more medications and miss more doses.

So what have we done? We’ve tried to reduce the number of pills. Fewer pills, fewer times a day, with fewer adverse effects, and fewer drug-drug interactions, so that people can adhere to and have high levels of drugs throughout the dosing period. Now, that may come at a cost. It may come as an improvement in health care. If somebody can inherently be more adherent to medication because the dosing has been simplified, I see that as a benefit. It may cost the health care system some money, but in the long run, we may have less resistance. When I first started as a medical student at Johns Hopkins [University], I worked in an STD [sexually transmitted disease] clinic, and the treatment for chlamydia was tetracycline 4 times a day on an empty stomach. Doxycycline had become available, but it was more expensive and it was 1 pill twice a day, and so there were discussions about cost. “Well, let’s give people the cheaper medicine. It’s 4 times a day on an empty stomach, but it will work if they take it.” But fewer people took it, and as a result they had less effective treatment until we were able to move to something that had greater adherence. Ultimately you would have better outcomes. There was a cost difference at that point, but I think it made a difference in how we treated disease.

Ryan Haumschild, PharmD, MS, MBA: I love the way you led in because it’s all about the patient, and making sure we’re supplying them a therapy that not only works but also is realistic for them to be successful and adherent, to maintain those therapeutic drug levels. I think that’s a great theme that carries forward.

Transcript edited for clarity.