Special Considerations in HIV Management - Episode 3

Today's HIV Treatment Challenges

Peter L. Salgo, MD: What are some of the challenges? Are these side effects to these drugs? What are we talking about?

Elly Fatehi, PharmD, MPH: So, we’re in an age where we have medications that you need to take every day and you can basically manage HIV. It has become a chronic disease state, and just like every chronic disease state, you have to take your medication every day. And that’s the biggest challenge.

Peter L. Salgo, MD: Can I stop for just a second? Another definitional issue. Is it a disease? If you have HIV but it’s not manifesting itself with any symptoms because you’re taking medicine, is that a disease?

Michael Sension, MD: Boy, that’s a good question. I think that has evolved over the years. I look at HIV now in a slightly different way. If you have high blood pressure, but you take a medicine, and every time we measure your blood pressure, it’s 120/80, do you have high blood pressure? You have a chronic condition that you’re managing. But every time when we measure your blood pressure, if it’s 120/80, do you have the disease of high blood pressure or do you have a manageable condition? And if somebody has HIV currently and they take their medicine every day, and every time we measure how much HIV is in their body, we cannot measure anything.

Peter L. Salgo, MD: That’s interesting.

Michael Sension, MD: Do they have a disease?

Jeffrey Dunn, PharmD: But the key thing though is if you stop the medication, then you have symptoms, so therefore, you don’t ever get away from the disease.

Elly Fatehi, PharmD, MPH: You can’t eliminate it completely because you’re measuring the amount of HIV in your blood. Do we know how much is in your cells, how much are in your organs?

Peter L. Salgo, MD: But if it’s not affecting your cells or your organs, is it causing disease?

Elly Fatehi, PharmD, MPH: Well, what about chronic inflammation that comes with it?

Peter L. Salgo, MD: When you knock it all down, it’s interesting, huh? What about long-term medication adherence issues? These are issues that now pop up. What do we do about that?

Elly Fatehi, PharmD, MPH: That’s probably the biggest challenge that I think we’re facing.

Peter L. Salgo, MD: Why is it a challenge at all?

Jeffrey Dunn, PharmD: But that’s the key. In any chronic disease, persistency and compliance are probably always the number one issues. It’s just because it’s almost like a catch-22; the better your control, the better you’re managed. Sometimes you can become insensitized to it, right?

Elly Fatehi, PharmD, MPH: It’s human nature. So, there’s medication fatigue.

Jeffrey Dunn, PharmD: But even with symptomatic diseases and things patients feel, patients still are not compliant and there’s a lot of reasons that contribute to that. That is always going to be a huge issue.

Peter L. Salgo, MD: Human beings are a mystery. You’ve got a potentially lethal problem. Here’s a pill. It’s well tolerated. Take it and the lethality goes away. Why won’t you take this?

Jeffrey Dunn, PharmD: And we’ll talk about this later, but there are a lot of things that we can do to address that, and I think we all have a role in that. Compliance and persistency will always happen.

Peter L. Salgo, MD: Now, technically, we take some drugs and there is resistance to some of these drugs, right? So, that is an issue. How bad a problem is that?

Elly Fatehi, PharmD, MPH: So, if you’re adherent, you shouldn’t have to develop resistance. Resistance comes from nonadherence. The HIV virus is smart, and it can mutate, and if you’re adherent to your medications, you should not develop resistance. And I think that’s a major issue.

Michael Sension, MD: And there certainly has been progress that has been made through the years, and I’m thankful to the pharmaceutical world and their development of newer drugs. Some of the medicines we had to give people in the 90s, and even before, were many pills dosed multiple times a day with many side effects.

Peter L. Salgo, MD: We see AZT (azidothymidine), awful drug.

Michael Sension, MD: Right, that was one. The first regimens were referred to as cocktails. My father was a Baptist minister. Nobody drank but I was at a meeting in Chicago a few years ago and I was down in the lobby and they had a cocktail menu. And I looked at it and each drink had a paragraph of multiple ingredients, and all of a sudden, I realized, “Aha, a cocktail!” That explains the 18 pills back in the 90s, and 12 and 15.

Peter L. Salgo, MD: Shaken, not stirred.

Michael Sension, MD: With multiple ingredients, and we really referred to it as a cocktail. We don’t refer to 1-pill-a-day regimen today as a cocktail.

Jeffrey Dunn, PharmD: I was just going to say, I totally agree with my colleagues that we’ve made a lot of progress in this area with better drugs that are safer, better tolerated, fewer drug interactions. But education is always going to be an issue. Persistency is always going to be an issue. But I just wanted to add a little bit of a payer perspective. HIV is one of the top 5 or 6 categories in terms of cost for specialty, under specialty for most payers. And along with maybe hemophilia, it is really the only category that’s not managed right now. So, this is going to get a lot of attention. It has really been hands-off. We’ve seen a lot of price increases over the last few years. I don’t know if there’s any contracting. If there’s contracting, there’s very little contracting, so there are really no price concessions. So, it’s going to lead to some other discussions here shortly if we don’t do a better job of collaborating. And I think, to me, that’s one of the biggest challenges is it has been hands-off. Payers are told you can’t touch this, but if you look at this and like any other specialty disease, more and more the total cost of the category is driven by the drugs. So, if we don’t have better conversations between all the different stakeholders, we might end up in a place that none of us want to be.

Peter L. Salgo, MD: Alright. But all that I know is if you take a look at the HIV population going forward, to me, when I read the literature, what I read about is, how do you handle an aging population? And occasionally, there are drug-drug interactions because some of these antiretrovirals do have interactions with drugs: antihypertensives, cardiac drugs, diabetic drugs. That’s fascinating and boy, is that a great place to have landed, yes?

Michael Sension, MD: Yes. We now know that over half of all of our patients are over the age of 50. As people are not dying with HIV, they’re living with HIV and they’re living longer. And as people age, they often will require hypertension, hyperlipidemia, perhaps some diabetes medicine. And so, there are drug-drug interactions definitely to be seen.

Jeffrey Dunn, PharmD: That’s one of the things I want to come back to later is how we holistically do that, and I think a payer has a huge role in doing that.

Peter L. Salgo, MD: I do, too. I’ll tell you one thing that struck me. There were articles about how do we handle obesity in the HIV-positive population when we all know that in the early days of this epidemic, they died as skeletons. It was a skeletonizing inanition-inducing disease. And now, like anybody else, how do we go to the gym? I’m telling you, this has been remarkable from a clinician’s perspective.