From HIV Treatment Switching to Disease Prevention

AJMC: Despite substantial therapeutic advances since the 1980s, the US is not on pace to achieve the goals of the Ending the HIV Epidemic (EHE) public health initiative.^1,2 Why do retention of care and achievement of virologic suppression among people with HIV (PWH) remain problematic?²

APPLIN: After nearly 20 years in HIV care, I’ve seen that HIV follows people through every season of life. When life is stable, patients stay in care and maintain suppression, but when challenges arise—such as substance use, housing insecurity, or loss of insurance—it can be hard to stay engaged. For many women, family and caregiving often come first, and their own health becomes a lower priority.

Our health care systems treat disease well but often fail to support patients through these changing circumstances. The Ryan White model stands out, because it integrates medical, behavioral-health, and case-management support.³ Programs using this multidisciplinary, low-barrier approach consistently show higher retention and viral-suppression rates.

However, not all patients have access to that level of care. Broadening such models beyond federally funded programs could close gaps and move us closer to the goals of the EHE initiative.

AJMC: Among virologically suppressed PWH, how do you balance the treatment goals of maintaining viral suppression and managing comorbidities?

APPLIN: HIV is a chronic condition. The more trust we build with patients, the better we can manage HIV and comorbidities. Taking a holistic approach helps us look beyond viral suppression to the other conditions that affect long-term health, like cardiovascular disease, diabetes, and kidney disease. These are all interconnected. When diabetes and HIV are both controlled, for example, there is less inflammation and strain on the kidneys, which can slow the progression of kidney disease. Helping patients see how one condition influences another allows them to take a more active role in their care.

I also ask patients about their priorities. Many patients stay consistent with HIV medications but struggle to manage hypertension or diabetes. Understanding why HIV feels easier to control helps identify barriers—like work schedules, adverse effects (AEs), or complex dosing—that we can address through education and support.

By combining education, communication, and encouragement, we can empower patients to see their health holistically, maintain viral suppression, and improve overall well-being.

AJMC: How does a patient’s quality of life (QOL) factor into your treatment decisions?

APPLIN: QOL is a major factor in treatment decisions. When choosing a regimen, I think about how it fits into a patient’s daily routine and whether AEs could interfere with adherence. Helping patients understand how to manage those AEs is as important as selecting the right drug.

Potential drug-drug interactions (DDIs) impact QOL and should be considered, too; most patients take other medications for chronic conditions. Choosing regimens with fewer interactions can simplify care and improve both QOL and consistency.

Disease barriers to drug resistance also impact QOL and treatment decisions. If the HIV virus has a high barrier to resisting a drug, missed doses can be managed, and long-term virologic control can be maintained. Finally, stigma remains a real issue surrounding QOL and treatment. Selecting discreet, easy-to-manage regimens and addressing that fear help patients feel empowered in managing their own health.

AJMC: What clinical rationale exists for switching antiretroviral therapy (ART) for a virologically suppressed PWH?

APPLIN: When considering a switch, it is best to confirm that a patient has sustained virologic suppression for at least 3 to 6 months. Once suppression is stable, optimization—including treatment switching—can be explored.

Regimen simplification is the most common reason for treatment switching. Patients may move from multi-tablet regimens to a single tablet once daily, or from twice-daily dosing to a once-daily option. Updating older regimens to newer formulations can also improve tolerability and adherence.

Sometimes, I initiate the switching discussion. If a patient struggles with occasional missed doses, I may recommend a regimen with a higher resistance barrier to protect long-term efficacy. Other times, the conversation begins with the patient, who may have heard about a new therapy or seen a partner on a different regimen.

In either case, the goal remains the same: to sustain viral suppression while improving long-term QOL and adherence.

AJMC: How—if at all—might AEs from ART or anticipated DDIs impact this treatment decision?

APPLIN: When a patient reports AEs, it is important to respond and explore solutions rather than immediately change therapy. Often, we can manage AEs by adjusting how the medication is taken—for example, taking it with food instead of on an empty stomach or shifting the dosing time to later in the day. These small changes can resolve AEs while maintaining viral suppression.

If AEs persist, I evaluate whether a regimen change is appropriate. Any new regimen must be fully active against the virus, so I review resistance history. Fortunately, today’s ARTs tend to have fewer AEs, so treatment changes are less common than they once were.

DDIs are handled similarly. When possible, I modify the non-HIV medication first. For example, boosted agents can interact with some statins or inhaled steroids like fluticasone; changing the statin or steroid can often solve the problem. If not, switching from a boosted to an unboosted regimen may eliminate the interaction while maintaining effective HIV control.

AJMC: You have worked extensively with pregnant women who are HIV-positive. What additional considerations does pregnancy add to decisions about treatment and treatment switching?

APPLIN: We now have growing evidence supporting the safety of many HIV medications in pregnancy. Historically, pregnant women were excluded from clinical trials, which limited available data, but newer studies and updated national guidelines have expanded our options and improved confidence in treatment choices.

When I counsel women of childbearing potential, I start by considering what works for them now and what they could continue safely if they become pregnant. Many pregnancies are unplanned, so it is important that their regimen has both a strong safety profile and a high barrier to resistance to carry them through pregnancy and beyond.

For patients already on therapy, I discuss their pregnancy intentions and review whether their current regimen could be continued if they conceive. The goal is always to minimize disruption—keeping women stable through pregnancy, breastfeeding, and later in life whenever possible.

AJMC: As you optimize ART regimens with your patients with HIV, how do you maintain virologic suppression without jeopardizing future treatment options (eg, through drug resistance to monotherapy)?

APPLIN: Before making any treatment switch, it is essential to understand a patient’s resistance and treatment history. If resistance data are not available, reviewing prior regimens can still provide clues about possible resistance patterns and guide safer decision-making.

Another key factor is the barrier to resistance. Each drug class offers a different level of protection—non-nucleoside reverse transcriptase inhibitors, for example, have a lower barrier than protease inhibitors. When optimizing therapy, the goal is to maintain or increase that barrier to strengthen durability and long-term viral control.

By understanding resistance history and choosing regimens that preserve or enhance protection, we can optimize treatment without limiting future options.

AJMC: What additional factors do you consider in optimizing treatment?

APPLIN: Patient preference is important. When someone asks about switching to a specific regimen, I try to understand their underlying motivation. I ask, ‘What interests you about that medication?’ or ‘What would improve for you if we made that change?’ Sometimes the reason is convenience—fewer pills, no food requirement—or it may be as simple as wanting to match a partner’s regimen.

Once I understand their perspective, we discuss the details together. I explain what the new regimen involves—whether it requires multiple pills or clinic visits for injections or if there are coverage issues. These conversations often help patients clarify what they really want and whether the switch fits their lifestyle.

If a preference aligns with clinical goals, resistance history, and adherence needs, I will support it. If not, we discuss why continuing the current regimen might be best. Engaging patients in these discussions helps them feel heard and informed, which ultimately strengthens adherence and satisfaction with their treatment.

AJMC: In your work precepting students and speaking publicly, what key points about HIV treatment in 2025 do you work to reinforce?

APPLIN: My passion is expanding access to HIV care through a low-barrier approach. That means making sure that as providers and systems, we are not adding obstacles that keep people from getting what they need—consistent care, lab monitoring, medication access, and wraparound support. Too often, we fall short because we do not meet patients where they are or help them overcome challenges like substance use, unstable housing, or transportation. These barriers prevent engagement, retention, and adherence.

While treatment options have advanced, access to multidisciplinary, low-barrier care is still uneven across the country. I emphasize to students and colleagues that equitable care means reducing system-level barriers, not just prescribing medication.

Another ongoing issue is stigma, which affects different communities in different ways and remains a major obstacle to care. We must work within communities—especially communities of color—to dismantle stigma. Only then will progress in treatment translate into true progress in outcomes.

AJMC: What policy changes on the health care–system, state, or federal level would you like to see that might encourage more equitable access to HIV treatment today?

APPLIN: Policy change surrounding prevention is key. The Ryan White model has proven effective in treatment because it provides comprehensive, low-barrier, multidisciplinary care, but we do not have a similar structure for prevention. If someone comes to my clinic living with HIV, we are addressing the disease too late. We need to apply the same model—community-based, team-driven, and well-funded—to prevention if we want to make real progress toward the EHE goals.

That shift requires stronger investment and policy focus on education and access to PrEP (pre-exposure prophylaxis), especially in communities of color and among men who have sex with men. Funding for HIV treatment is substantial, but prevention funding still lags behind. I often see new diagnoses in patients unaware of PrEP, highlighting missed opportunities that stronger outreach and education could prevent. A status-neutral approach would ensure that whether a person tests negative or positive, they receive the same level of quick access, high-quality care, and medication support.

Finally, supporting culturally grounded community leadership is essential. Trusted voices—particularly among Black and Hispanic communities—can speak authentically about testing, prevention, and stigma in ways top-down campaigns cannot. Empowering and funding these leaders is key to building lasting, equitable change in HIV prevention and care.

REFERENCES

1. National HIV/AIDS Strategy 2024 Progress Report. HIV.gov. 2024. Accessed June 6, 2025. https://files.hiv.gov/s3fs-public/2024-NHAS-Progress-Report.pdf
2. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 territories and freely associated states, 2022. HIV Surveillance Supplemental Report. 2024;29(2). CDC. Accessed September 22, 2025. https://www.cdc.gov/hiv-data/nhss/national-hiv-prevention-and-care-outcomes.html
3. Ryan White HIV/AIDS Program. Health Resources & Services Administration. Accessed October 13, 2025. https://ryanwhite.hrsa.gov/