Special Considerations in HIV Management - Episode 4

Goals of Therapy in HIV Infection

Peter L. Salgo, MD: What are the goals of therapy here anyway? What are you looking for first?

Elly Fatehi, PharmD, MPH: Viral suppression. Like we mentioned earlier, HIV is something where you can manage it. Your viral load can go suppressed and can be undetectable, and undetectable can be untransmittable. There does not need to be new cases of HIV.

Peter L. Salgo, MD: Oh wow, does not. Every time somebody opens his or her mouth here, I’m just shocked with wonder and happiness.

Michael Sension, MD: If we could test everyone in America and everybody who’s HIV-positive, mandate in some way that they all get in therapy, and if we do directly observe therapy where we watch everybody take their medicine 100% of the time, we will eradicate transmission. Everybody would go to undetectable amounts of virus, and they would no longer transmit HIV.

Peter L. Salgo, MD: You can’t keep people from crossing the street on a red light. How are you going to get them to take drugs?

Michael Sension, MD: Well, you make things simpler. You make things more doable, and I think that’s part of our discussion today. What’s our current perspective on management so that the maximum number of people will be successful?

Peter L. Salgo, MD: It seems to me that there are 2 separate branches that all 3 of you mentioned. The first is the individual who’s HIV-positive. Treating that person keeps the viral load down to undetectable, T4 cell counts go up, so that person stays healthier. But then there’s this whole public health aspect to it, and that’s got to be factored into your calculations, too, right? It may be expensive to treat somebody individually for HIV, but you’re going to keep a whole circle of people from getting it.

Jeffrey Dunn, PharmD: Right. Absolutely. It’s just the total cost of the category is increasing, but it’s driven by the drug prices and the drug increases. And so, that’s where the conversation needs to be. But you’re absolutely right, we want to treat these patients appropriately. There’s not a disconnect in terms of what our goals are.

Peter L. Salgo, MD: I was just thinking about this as you were speaking and 2 things occurred to me. Yes, it would be cheaper if nobody got AIDS from HIV. But in a most bizarre, dark way, it might be cheaper if they got it and died. There’s that, too.

Jeffrey Dunn, PharmD: But prevention. Like any other disease, prevention is usually more cost-effective than treatment.

Peter L. Salgo, MD: Yes, we don’t want the second alternative.

Jeffrey Dunn, PharmD: There are definitely better ways to approach this problem.

Michael Sension, MD: And whether that’s preventing HIV or preventing advanced HIV once somebody has HIV from effective care.

Peter L. Salgo, MD: But once they’ve got it, you can still treat them, yes?

Michael Sension, MD: Yes.

Jeffrey Dunn, PharmD: We can treat every effectively.

Michael Sension, MD: I don’t work for the pharmaceutical companies, but what I see is some of the benefits that we’ve seen through new drug development over the last 20 years have been improvements in safety, improvements in tolerability, and improvements in simplicity. But those have come at a cost. So, the trade-off is, do we want to go backwards? From a payer perspective, do you want to say, “Oh, I just want to take the cheapest therapy, but realize that it may be more problematic”?

Jeffrey Dunn, PharmD: Or can we take a step sideways? I don’t think anybody agrees that we need to go back to the days of the cocktails, as you mentioned, the 20 tablets 4 times a day. But can we do a better job of going from, say, 1 tablet once a day to say 2 tablets twice a day if it saves a lot of money? Are there ways? I think those types of conversations…

Peter L. Salgo, MD: Does that even complete adherence? Then you have a problem with that.

Jeffrey Dunn, PharmD: Yes. So, we don’t want to affect adherence, but I would argue that 2 tablets once a day or 3 tablets once a day is very different than 20 tablets 4 times a day like back in the old day.

Peter L. Salgo, MD: That’s a reductio ad absurdum. Nobody is going to go back to 20 pills a day.

Jeffrey Dunn, PharmD: No. But I think if you look at the market—correct me if I’m wrong based on what your experience is—the majority of patients are still not on single tablet regimens for whatever reason.

Elly Fatehi, PharmD, MPH: They’re not.

Jeffrey Dunn, PharmD: So, is it appropriate for us to collectively move in that direction, or are there opportunities to take advantage of generics? And maybe more cost-effective single tablet regimens and other things that we haven’t had conversations about previously?