Non–treatment-naïve patient considerations are explored by key opinion leaders.
Eugene McCray, M.D.: Drugresistance testing must be performed before initiation of therapy in these treatment-experienced patients, especially because of the concern you mentioned. In addition, you need to make sure, as I said, you have a good history of the patient and understand what drugs they’ve been exposed to in the past because that will help you decide what drugs to use. The other thing that’s important is if the patient has any history of being exposed to integrase inhibitors, what we call INSTIs [integrase strand transfer inhibitors], you should think about waiting before you start a drug, especially before you start an INSTI, and do resistance testing. And ask your doctor or the laboratory to specifically do resistance testing for INSTIs, because these are not routinely looked at in resistance testing, so you have to ask for it.
The other things that are important are that you get the patient’s full ARV [antiretroviral therapy] history, and you also want to review their past virologic responses. One of the things I did when I was seeing patients is, if we were going to see a new patient who was restarting drugs or had been nonadherent to a drug, we asked for a copy of their complete HIV [human immunodeficiency virus] treatment history from their prior physician. That’s important because you want to review all their past virologic responses. Then you want to ask about all past associated toxicities and intolerances, and you want to obtain and review their cumulative resistance test results. So, you have to be very diligent with these sorts of patients because what you don’t want to do is create a situation where you’ve got an individual who might be resistant to two classes of drugs and you inappropriately put them on three drugs, and they’re only sensitive to one. You have the possibility then of creating a situation where the person might develop acquired resistance to now a third class or possibly a fourth class of a drug, and then their treatment options are severely limited.
Steven Peskin, M.D., MBA, FACP: In looking at or thinking about the economic burden of HIV and where it falls within other chronic conditions, it certainly will vary from plan to plan and payer to payer, based on geography, sociodemographics, demographics, area of the country. Where I was most recently, in New Jersey with Regional and Blues Health Plan Profiles for Horizon, I would say it was of moderate importance, perhaps a bit tilted as higher importance in our Medicaid population, which numbers almost 1 million persons. HIV is an area that health plans have a focus on from the standpoint of chronic condition management, medication persistency, adherence, endurance. It is one of those conditions that payers tend to pay attention to and typically have some care management oversight. The other thing I would mention, as payers are increasingly involved in value-based models with clinical organizations, those clinical organizations similarly have care coordination and care management programs and activities and individuals who focus on chronic diseases like heart failure and HIV.
Transcript edited for clarity.