Special Considerations in HIV Management - Episode 15
Peter L. Salgo, MD: What are the therapies that are in the pipeline now for HIV? They’re going to delineate this disease within the next 2 months, right?
Michael G. Sension, MD: I don’t think so. But we’re going to have more options available to us. In other words, we’ve been able to go from 18-pill-a-day regimens—taken 3 times a day with special restrictions on how they have to be taken—to, in many cases, 1 or 2 pills once a day. And so, we think that we’ve arrived and that once-a-day dosing is where it’s at. But who knows? Maybe we’ll be able to push that envelope and go to once-a-week dosing with longer acting oral drugs. Something very much on the horizon would be long-acting injectable drugs, where somebody could literally have an injection once a month or once every 2 months to maintain and manage their HIV.
Peter L. Salgo, MD: Are these drugs actually in the pipeline now? What do we know that’s coming down the road?
Michael G. Sension, MD: Yes, they are.
Peter L. Salgo, MD: That’s exciting.
Michael G. Sension, MD: There’s a 2-drug combination that’s being developed, but it may not be for everyone. You would have to ask yourself, would you want to come and get an injection in both of your buttocks, both sides, once a month versus taking 1 pill once a day or 2 pills once a day? Some people are going to weigh in and say, “I would much rather take a pill than to have to go to my doctor every month and get an injection on both sides of my buttocks.” Other people would say, “Absolutely, give me the shot.”
Peter L. Salgo, MD: In the cholesterol-lowering drug sphere, that’s what’s going on right now. You come in every 2 weeks, we give you a shot, and you go home. You don’t necessarily need pills—maybe you would—but that’s it. People opt for injections.
Michael G. Sension, MD: Right. But if your choice was to see your doctor twice a month versus once every 6 months or once every 4 months, then people have to say I’d rather...
Peter L. Salgo, MD: It depends on whether you like your doctor.
Michael G. Sension, MD: Exactly.
Jeffrey D. Dunn, PharmD, MBA: You could argue, though, that maybe interaction with the provider is a good thing. I think one of the things that has been alluded to before by Elly is, what other things can we bring to the table? And again, it underscores what we’re talking about with collaborating rather than having an antagonistic relationship, because I really do think the payer is unique. We have complaints. We know if they’re taking their medications. We know if they’re not. We know what other doctors they’re seeing. We know what other disease states they have. We have nurses and pharmacists who can interact with these patients and really help the patient. So, I think it’s a resource that is being better utilized in other disease states that can be probably better utilized in HIV.
Peter L. Salgo, MD: I get the sense that because we are down to 1 or 2 pills a day, we’re down to undetectable CD4 counts. We’re looking at normal T4 counts. A sense of urgency, a sense of crisis, and a sense of fear and panic are just going away. Is that a good thing Elly?
Elly Fatehi, PharmD, MPH: Oh, absolutely. I think we’re at a place where, like I said earlier, HIV is managed and can be controlled. We don’t necessarily need to see any new cases. I think we can significantly decrease incidents and manage prevalence.
Peter L. Salgo, MD: But isn’t there a risk? If the sense of urgency goes down, then the sense of taking HIV for granted goes up.
Jeffrey D. Dunn, PharmD, MBA: Yes, you focus on other things.
Peter L. Salgo, MD: We see a spike, and suddenly this disease is back.
Michael G. Sension, MD: It’s interesting. Who are the people in whom we’re seeing the higher rates of new infections? Young men who have sex with men, young gay men, 15 to 24 years of age. If you think about it, a 20-year-old can’t identify with Magic Johnson. They weren’t even alive when Magic Johnson was playing basketball. They certainly don’t know who Rock Hudson is. Some of the recognition that we might have had with the early days of HIV, our younger population doesn’t necessarily have. Maybe the education isn’t there in the school systems. Maybe there has been some complacency. So, I have a concern about some of our younger population, where the message isn’t getting out.
Peter L. Salgo, MD: We can’t let down our guard, can we? This is going to pop back. This virus is out there. If we keep pushing it down with drugs, there’s a chance on one side to eliminate it; but on the other side, if you take your eye off the ball, it’s back. To some degree, that’s your responsibility too. You’ve got to continue to pay for this stuff, right? You recognize that. It’s only a question of how much you’re willing to pay.
Jeffrey D. Dunn, PharmD, MBA: Right. We’ll pay for the right thing, absolutely. We want to do that.
Michael G. Sension, MD: Can I quote you on that?
Jeffrey D. Dunn, PharmD, MBA: Absolutely. Nobody wants to say no. It’s just that we want to put our dollars where it makes the most sense.