Dr Haumschild leads a discussion highlighting goals of therapy and social determinants of health affecting MDR HIV diagnosis and treatment.
Ryan Haumschild, PharmD, MS, MBA: Mr Driffin, a question within the same question; we know that these patients with multidrug resistant [MDR] HIV [human immunodeficiency virus] are vulnerable. We know that people are used to this because they could have more illnesses, or if they weren’t able to sustain viral suppression, they might have other comorbidities that are more prevalent. Has this been your experience as an advocate across this patient population? Is this something we should be aware of as we’re making treatment decisions?
Daniel Driffin, BS, MPH: Most certainly. I definitely think we have to always be mindful of whole-person health care. When we define whole-person health care, you have to go through some quick questions, and those questions must exist around the intersection of housing. Is your patient someplace safe at night? Is your patient eating a healthy diet? Does your patient have adequate transportation to get to and from the medical home? Those are the things that come to mind immediately. I think that further conversation is bridging toward what medicine or medical regimen looks best for you. Even the journey I’ve been on, specifically as a person living with HIV, is very similar to what Dr Sension said. I started on a 1-pill-a-day regimen. When COVID-19 set in, I [was less likely to take my medications consistently] because I wasn’t traveling to eat lunch. I’m now on a bimonthly injection, and it’s the best thing ever. Going the gamut from taking pills to now just getting an injection every other month, I think those are the conversations we have to have for all people living with HIV [who are following] medical guidelines.
Ryan Haumschild, PharmD, MS, MBA: What a relatable comment. I appreciate you being vulnerable and sharing your journey within the same thread. Mr Driffin, I have another question for you because diversity, equity, and inclusion are so important. We can’t just talk about it. We need to make sure we’re actually living it, from an organizational perspective, a payer perspective, and a patient-advocate perspective. In your opinion, in your expertise, how do social determinants of health impact risk factors for MDR HIV, as well as the ongoing care of patients? You mentioned transportation vulnerability, food vulnerability, and housing. I think those are essential. Talk to us a bit and talk to our viewing audience about how these play a role and why they need to be considered as part of the treatment and overall care of the patient population.
Daniel Driffin, BS, MPH: Absolutely. Again, it goes back to that client-level holistic health care. I’m a firm believer that pills will not fix everything. If you are not in a positive support system among community members, including family or even chosen family, that goes into exacerbating social determinants of health. If you cannot have a free-flowing conversation with your medical providers, even if your medical providers don’t look like you, that’s a big thing. It connects back as you were saying to diversity, equity, and inclusion. We have to dive deeper as we think about who are the people we’re hiring, who are the people we keep on staff, and how best can all communities [do what they need] to be the healthiest?
Ryan Haumschild, PharmD, MS, MBA: Excellent. Dr Sension, after we’ve heard all of this, I want you to review with us potentially what are the goals of therapy for the treatment of patients with MDR HIV? And what should be on the front line for our practitioners as they’re reviewing this patient population?
Michael Sension, MD: I think we want complete virologic suppression. We want patients to be undetectable. It wasn’t too long ago when we really didn’t think we could achieve that. When somebody developed multidrug resistance, it was just damage control. We tried to keep the viral load as low as possible. We talked about holding regimens, we looked at what was coming in the pipeline, and we thought, what could we do that might impact viral fitness, to make a less fit virus? But we never thought we could achieve virologic suppression. Now I think that has changed, and I think the goal, even in MDR individuals, is to try to come up with a new regimen that could indeed result in complete virologic suppression.
Ryan Haumschild, PharmD, MS, MBA: Excellent. Dr Lopes, from a payer’s perspective, as we think about goals of therapy, I’m sure they’re similar, but are there any other goals you’d be looking for in the treatment of these patients with MDR HIV?
Maria Lopes, MD, MS: No, I think Dr Sension said it. It’s viral suppression. Also as you age, you’re going to develop other comorbidities, so think about a holistic approach because again, the success story in HIV is that patients are dying with HIV instead of from HIV. [We need to] think about a medical home in terms of patient whole health, as Mr Driffin described. But also, how other comorbidities impact living with HIV, as well as the patient-centered approach, and care coordination as mentioned, so that you’re adherent. And hopefully, if you do have other comorbidities, [there is] adherence overall, so you’re out of the hospital, you’re living a productive life, and hopefully reducing costly events, whether they’re cardiac, endocrine, or otherwise. It’s a great success story in terms of how we live longer, but as we live longer, how can we develop a more holistic approach? That also includes behavioral health aspects, psychosocial, dealing with depression, and dealing with the social determinants, as mentioned before. How do we do a better job with comprehensive care? That may also involve multiple specialists, or the PCP [primary care physician] and multiple specialists. Again, [we must take] a holistic approach for the type of patient we’re seeing age with HIV.
Transcript edited for clarity.