Medications come and go, but the goal is still the same
Positively Aware Ross Slotten, MD
Ross Slotten, MD

For those of us who have been treating people with HIV/AIDS since the earliest days of the epidemic, 2020 is a completely different world. Today, we take for granted that nearly everyone with HIV who comes into our care not only can be successfully treated with an array of life-saving medications but is also likely to live a normal lifespan, unless diabetes, cancer, heart disease, or some other illness cuts their lives short. If they adhere to their medication regimens, people living with HIV will not die of AIDS. With several dozen anti-retroviral agents at our disposal (and more in the pipeline), you almost have to go out of your way to fail treatment and
die of an AIDS-related problem.

Of course, there still exist areas in the United States where people living with HIV do not have easy access to treatment. And those at highest risk, especially young LGBT men of color, often don’t perceive of themselves as being at risk or may not know much about HIV and other sexually transmitted diseases. Unless as a society we address issues of inequality and bring the marginalized into the mainstream, the epidemic will continue to rage, even though the epidemic could, in theory, burn out in a generation or two with universal treatment of those with HIV and universal prevention in those at risk. With no vaccine or cure in sight, that is our best hope.

In this issue, I would like to focus on the highly active anti-retroviral treatments (or HAART) that most experts prefer to prescribe. For the most part, I agree with the Department of Health and Human Services guidelines for the use of antiretroviral agents in adults and adolescents with HIV. The top-tier agents have been given an A1 rating, “A” standing for strongly recommended by an expert panel and “1” for having undergone one or more randomized trials with positive clinical outcomes and/or validated laboratory end points (undetectable viral loads, for example). Those rated “B” are moderately recommended and those rated “C” are recommended only under certain circumstances.

In reality, many different regimens will work beautifully. Crixivan, AZT, and 3TC are just as effective as Biktarvy and saved many lives, but no one in this era would prescribe Crixivan, AZT, and 3TC because of pill burden, inconvenience, and unacceptable long-term side effects such as disfiguring lipodystrophy.

I have elected not to comment on Complera and Stribild this year because they have been replaced by Odefsey and Genvoya, respectively, which are essentially the same but have better safety profiles than their progenitors. I’ve also omitted Epivir (3TC), Emtriva (FTC), Ziagen (abacavir), Edurant (rilpivirine), and Viread (TDF) because of redundancy (they are components of other regimens). I have written about some of the so-called generic medications, such as Cimduo and Symfi, not because I believe in them, but because they are marketed as less expensive alternatives to the top-tier agents.

The issue of cost is important and complicated. How are HIV medications priced and why? All HIV medications are expensive, whether the price is $1,500 per month or $3,000 per month. Those costs are average wholesale costs. Only people without insurance would actually pay full price. Don’t feel sorry for your insurance company and don’t believe a word about “true costs” from the pharmaceutical industry. The relationship between the insurance and pharmaceutical industries is complex, unfathomable, inscrutable, opaque—in short, anything but transparent. These two devils play a game that excludes, but nevertheless ensnares, most of us.

The current paradigm of HIV treatment is a nucleoside backbone (TDF/FTC; TDF/3TC; TAF/FTC; or ABC/3TC) plus an integrase strand transfer inhibitor (INSTI) or boosted protease inhibitor (PI). That paradigm may shift. Two-drug combinations, including those without nucleosides, show promise in some patients who have never been treated before. Crixivan and Kaletra, once kings in the HIV-treatment world, are now nearly forgotten. In 10 years, Biktarvy and Triumeq may have joined them as newer treatments replace them. HIV drugs, and HIV drug combinations, come and go, which is why this HIV drug guide remains necessary and useful.