Challenges and Opportunities in the Management of Multi-Drug Resistant HIV - Episode 2
Dr McCray shares an encounter with “Patient X”, highlighting the barriers and challenges associated with MDR therapies in HIV treatment.
Eugene McCray, MD: There are no data available on the incidence of MDR [multidrug-resistant] HIV in the United States. However, there are data available on the prevalence of what we called transmitted drug resistance among persons [with a diagnosis of] HIV in the United States from 2014 to 2018. In an analysis of HIV sequences that were reported to the National HIV Surveillance System, from 2004 to 2018, there were 50,747 people who were reported to that system. Almost 10,000, or 19% of those people, had treatment resistance to at least 1 or more transmitted drug resistance–associated mutations, and these were to any drug class. Of those 50,747 patients that were reported to CDC, 2.6% had resistance to 2 or more drug classes. Also, there was another small percentage that had resistance to 3 drugs, and then there was 1 patient that had resistance to all 4 classes of drug. So drug resistance is there. They found in this study[’s data] that from 2014 to 2018, there was really no change in the percentage of MDR HIV from one year to the next. Similarly, the prevalence of transmitted drug resistance did not change overall or for any of the individual classes of drugs.
Patient X is someone that I actually [treated] a few years ago. He was a 30-year-old man who…self-identified as gay, and so that meant he was a man who was having sex with men. He [received a diagnosis of] HIV about 2 years before I saw him. We began treatment with oral antiretrovirals [ARVs] immediately following his diagnosis. At about the 2-year time frame he came in and said he was having trouble taking his medications as prescribed, and this was due to several things: he said that he had had inconsistent housing and a very hectic schedule, which was evidenced by the fact that he had missed appointments with his doctor and with the clinic. He also reported either forgetting to take his ARVs about 2 to 3 times a month or deliberately not taking them when he was staying with family or friends who did not know he was living with HIV. He also had a small problem with substance use. He regularly used marijuana and other recreational drugs to “relax” and he didn’t see the risk of missing doses of his ARVs because “I’m virally suppressed.” The other cofactor, I would say, is that he had a history of depression and posttraumatic stress disorder for most of his adult life, since he was about age 18 or so. This, along with his housing instability, his drug use, et cetera, really put him at increased risk for drug resistance. Essentially, moving forward a few years, he did have virologic failure, and when we did drug-resistance testing, he was resistant to at least 2 of the drugs he was currently on, and we had to then find an alternative regimen. I can talk later about some of the approaches that one needs to take when you have a patient like the one I’m describing.
Transcript edited for clarity.