That one pill, once a day ‘holy grail’ remains elusive for many of us who have been living with HIV for a number of years, and have been through a lot of different HIV medications—the term used for us is treatment-experienced.

Back to the future

One pill, once a day. That’s kind of been the HIV drug mantra ever since the first single-tablet regimen (STR) Atripla launched over 10 years ago. But it’s something that has continuously been out of reach for me—until recently.

When I started antiretroviral therapy not long after being diagnosed in 1989, I was on one medication, but it was AZT—taken several times a day. That’s all there was back then, and we now know that AZT by itself is suboptimal therapy, meaning it isn’t effective at suppressing the virus, and leads to resistance when taken on its own.

I kept trying different suboptimal regimens but it wasn’t until seven years later that I finally got on effective therapy, and it was difficult to take—one of the medications in my regimen came in the form of two pills three times a day, on an empty stomach, eight hours apart, while drinking 64 ounces of water daily. I ended up in the hospital with kidney stones one summer after attending a street fair and not staying hydrated. The drugs in the regimens that followed either caused massive diarrhea, rash, or nightmares—not to mention the body changes caused by lipodystrophy from some of the older drugs. 

Most of that is gone in the regimens available today for those newly diagnosed, many of which are one pill, once a day, with few side effects. But that one pill, once a day “holy grail” remains elusive for many of us who have been living with HIV for a number of years, and have been through a lot of different HIV medications—the term used for us is treatment-experienced (it’s nice to be experienced at something, I guess). 

For the last three or four years I had finally settled into a regimen that consisted of two pills taken once a day, which was a huge improvement over some of those earlier regimens. When they recently combined those two pills into one, it was a big moment for me. Here I was, almost 30 years later, and finally I was on a one pill, once-a-day regimen (Juluca). Woo-hoo! Of course, I still had to take other pills (for high blood pressure, cholesterol, my vitamins), but suddenly there was a shift in how I perceived my HIV treatment. It was just so easy. 

Some treatment-experienced individuals who are multi-drug resistant must still take handfuls of pills, sometimes multiple times a day, in order to manage their HIV. New drugs under investigation will help to address this by targeting HIV at different points in the lifecycle. Other drugs nearing approval later this year should be effective in some people who have developed resistance to existing drugs. The first single-tablet regimen (STR) with a protease inhibitor taken once daily may help improve adherence for those who struggle with it currently. 

Many of us are anxiously awaiting the long-acting injectables that are now in development, and expected to be approved next year. Simplifying treatment by using only two drugs instead of three is already happening, and more two-drug combinations are on the way. Whether there will be significant cost savings using generic versions of existing drugs remains to be seen, but more and more drugs are being approved as generic (as this issue went to press, a generic STR similar to Atripla was approved). 

In this year’s drug guide we’ve added information about cost-sharing and patient assistance programs for PrEP and PEP, as well as for those for HIV medications. But changes may be on the way for consumers, as some big health insurers no longer allow the amount of the co-pay cards to be applied towards their deductible or out-of-pocket maximum, or steer them towards other cost-containing measures such as step therapy or individual generics that break up an STR. Stay tuned. 

Dr. David Hardy joins us for the first time as the doctor for the 2018 HIV Drug Guide (is there a doctor in the house?), and talks about what lies ahead in “The Future of HIV Therapy”; renowned treatment advocate Moisés Agosto-Rosario provides the activist commentary; pharmacist Eric Farmer worked with Associate Editor Enid Vázquez on updating the HIV Drug Guide; and our beautiful cover and superb design of this issue come from creative director Rick Guasco and photographer John Gress. 

The medications used to treat HIV have changed (thankfully), but the goal of therapy remains the same—to suppress the virus and get to undetectable. The benefits include not only improved health, but also the fact that you can’t transmit HIV to others when you are on suppressive therapy and undetectable (U=U). That in turn helps break down the stigma often associated with HIV.  

And that’s a future we can all look forward to.. 

Take care of yourself and each other.