Hiv Medication Compliance Questions.

[wood]

So I have a friend who is HIV+, Healthy and undetectable.  However he has one problem in that he isnt always the best about taking his medication.  He usually forgets about once a week, sometimes twice a week.  AFAIK, he hasnt had any issue with this yet, and he is still on the same therapy (stribild) that he has been on for years.  

 

My main question is, what are the potential effects of this, and is he doing significant risk to his long term health by not being more conscience about taking his medication. He's not a large guy, so I would assume the blood serum level of any medication would be fairly high to begin with, but Im not sure if that would correspond to less chance of resistance.   

[fillmyholeftl]

While I certainly don't condone this, I have a good friend, HIV+ for over 20 years.  He has skipped his meds many times, sometimes for weeks at a time when traveling. He remains undetectable. In my work in HIV education, we are told that a one pill a day regime you can miss 1X/month.  If you are taking 2 pills/day its okay if you miss twice in a month. Like I said, I don't think anyone should make a habit of missing their scheduled dosing as consequences will vary greatly from individual to individual

[VersatileBreeder]

Based on what my doctor told me, Stribild needs to be adhered to at least 90% of the time to have the best strength against forming resistance. That being the case, that would mean that a person should not miss more than 3 days per month. Granted, doctors usually err on the side of caution and chances are the real world number might only be something lower like, say, 70% before resistance starts becoming a real issue. Still though, I would say missing 1-2 doses a week is not a good thing.

I have been on Stribild for about 15 months now and I have not missed a single day since I have been on it. The only slip I ever had was I once forgot to take it in the morning before work, so I took it in the late afternoon when I got home. Other than that, I have had 100% adherence and remain undetectable.

What your friend needs to do is incorporate taking his pill into one of his daily routines, like take it first thing in the morning (that's what I do as soon as I wake up), or take it when he brushes his teeth or with dinner, etc. It's really not hard to do. But constantly slipping up may down the line lead to resistance and that won't be fun for your friend. He will have to switch meds and his new meds might not be as easy on him as Stribild is, as in, it might give him one or two side effects he didn't have before.

[bearbandit]

Stribild is tenofovir, emtricitabine (the components of truvada), elvitegravir, and cobicistat. Truvada has an unusually long half life in the body and cobicistat is there as a booster, blocking the enzymes that the drugs need to me metabolised, so that they stay in the blood stream longer. The worrying one in this combination is elvitagravir with a half-life just under 13 hours. Also, as an integrase inhibitor, it's the most effective out of the working drugs in the combination. As fillmyholeftl says, missing once a month would be acceptable here, more than that is courting trouble.

As poptronic says, the friend needs too fit taking stribild into his daily routine, keeping the bottle next to the toothbrush, or on the pillow, else setting a reminder on his phone. A "reward" system, whereby the pill has to be taken in order to have a drink or a meal in the evening can work as bribery. Above all, your friend does not want to become resistant to the drugs in stribild: the more resistances you acquire, the more difficult medication becomes. A combination f side effects and resistances have led to my taking instead of one pill a day, somewhere nearer thirty...

[wood]

While I certainly don't condone this, I have a good friend, HIV+ for over 20 years.  He has skipped his meds many times, sometimes for weeks at a time when traveling. He remains undetectable. In my work in HIV education, we are told that a one pill a day regime you can miss 1X/month.  If you are taking 2 pills/day its okay if you miss twice in a month. Like I said, I don't think anyone should make a habit of missing their scheduled dosing as consequences will vary greatly from individual to individual

 

 

As fillmyholeftl says, missing once a month would be acceptable here, more than that is courting trouble.

As poptronic says, the friend needs too fit taking stribild into his daily routine, keeping the bottle next to the toothbrush, or on the pillow, else setting a reminder on his phone. A "reward" system, whereby the pill has to be taken in order to have a drink or a meal in the evening can work as bribery. Above all, your friend does not want to become resistant to the drugs in stribild: the more resistances you acquire, the more difficult medication becomes. A combination f side effects and resistances have led to my taking instead of one pill a day, somewhere nearer thirty...

This is pretty much what I was thinking as well.  My more selfish reason is that I really dont want him to become resistant to emtricitabine or tenofovir, as they isnt exactly good for our sex life and me on PrEP.

 

I think I am just going to get him something to help him remember.  He loves gadgets, so maybe there is something that will help.   

[bearbandit]

One consolation for you here is that resistance to tenofovir (which is the main workhorse in truvada) is pretty rare: PwHIV who have to stop it almost always have to do so because of its effects n the kidneys or bone density - even while it was trying to kill me tenofovir was on top of my viral load and CD4 count. Resistance to emtricitabine is just as rare, so the chance of someone becoming resistant to both is extremely low...

[fillmyholeftl]

This is pretty much what I was thinking as well.  My more selfish reason is that I really dont want him to become resistant to emtricitabine or tenofovir, as they isnt exactly good for our sex life and me on PrEP.

 

I think I am just going to get him something to help him remember.  He loves gadgets, so maybe there is something that will help.   

bearbandit can either support me on this or correct me, but I don't believe that his becoming resistant to either componentwould have any impact on the effectiveness of your PrEP.

[wood]

One consolation for you here is that resistance to tenofovir (which is the main workhorse in truvada) is pretty rare: PwHIV who have to stop it almost always have to do so because of its effects n the kidneys or bone density - even while it was trying to kill me tenofovir was on top of my viral load and CD4 count. Resistance to emtricitabine is just as rare, so the chance of someone becoming resistant to both is extremely low...

 

 

bearbandit can either support me on this or correct me, but I don't believe that his becoming resistant to either component would have any impact on the effectiveness of your PrEP.

 

While it is very rare to be resistant to both, it is one of the driving forces behind the only documented infections on people taking PrEP as directed.  I have talked to professionals about this and am 100% sure of it.  Resistance  to both means viral mutation that can in essence circumvent PrEP.  While this is VERY rare IMO its something to think about.  

 

My main concern however is that he is a young healthy guy that has his entire life ahead of him, and I dont want him to have to deal with drug resistance issues when it is needless.     

[bearbandit]

In every trial document I've read the few who did seroconvert have had their seroconversions explained by (a) either they started the trial already seroconverting or acquired the virus with a day or two of taking their first trial truvada or ( they were sloppy in their adherence and acquired HIV in a period of not taking the drug. In the PROUD trial I know from one of the organisers that they had several guys become "lost to followup", at least two of whom seroconverted in their absence from the trial: at least two of the guys were absent for such a time that they didn't have truvada for most of the time they were missing.

Resistance to emtricitabine and to tenofovir are two of the rarer resistances out there: a PwHIV in danger of developing both is far more likely to develop Fanconi's syndrome, which I did, which at 1 in 100,000 is way more likely than becoming resistant to both drugs in truvada. Tenofovir resistance would be more important as far as PrEP goes as emtricitabine is there basically to mop up what tenofovir missed.

The other thing to consider is what drugs are in the pipeline both for treatment and for PrEP. The integrase inhibitor cabotegravir (these days when you go for PEP you're most likely to get a couple of nukes and an integrase inhibitor) is showing a lot of promise and looks likely to be developed as an injectable drug: frankly I don't really see the point for treatment as the "supporting cast" would still be in pill form, but for PrEP, it would be fuckin' magic: one injection four times a year and that's it. Adherence problem solved.

 

And don't forget that Treatment as Protection (TasP) works too: in the PARTNER study, where the only safety net is an undetectable viral load (set at 200 despite moves forward in virology since the trial was established) the only seroconversions they've seen are invariably explicable by the fact that the negative partner played away from home. One conclusion already being brought from the PARTNER trial is that in a monogamous relationship as long as the poz person has a clinically undetectable load, the risk to the neg partner is as near to zero as possible.

Finally, as indicated above, other drugs for PrEP are in the pipeline: don't fall into the trap of thinking PrEP=truvada, because while that might be so today, it probably won't tomorrow. Truvada is simply the first drug to have proven it can do the job.

[wood]

In every trial document I've read the few who did seroconvert have had their seroconversions explained by (a) either they started the trial already seroconverting or acquired the virus with a day or two of taking their first trial truvada or ( they were sloppy in their adherence and acquired HIV in a period of not taking the drug. In the PROUD trial I know from one of the organisers that they had several guys become "lost to followup", at least two of whom seroconverted in their absence from the trial: at least two of the guys were absent for such a time that they didn't have truvada for most of the time they were missing.

Resistance to emtricitabine and to tenofovir are two of the rarer resistances out there: a PwHIV in danger of developing both is far more likely to develop Fanconi's syndrome, which I did, which at 1 in 100,000 is way more likely than becoming resistant to both drugs in truvada. Tenofovir resistance would be more important as far as PrEP goes as emtricitabine is there basically to mop up what tenofovir missed.

The other thing to consider is what drugs are in the pipeline both for treatment and for PrEP. The integrase inhibitor cabotegravir (these days when you go for PEP you're most likely to get a couple of nukes and an integrase inhibitor) is showing a lot of promise and looks likely to be developed as an injectable drug: frankly I don't really see the point for treatment as the "supporting cast" would still be in pill form, but for PrEP, it would be fuckin' magic: one injection four times a year and that's it. Adherence problem solved.

 

And don't forget that Treatment as Protection (TasP) works too: in the PARTNER study, where the only safety net is an undetectable viral load (set at 200 despite moves forward in virology since the trial was established) the only seroconversions they've seen are invariably explicable by the fact that the negative partner played away from home. One conclusion already being brought from the PARTNER trial is that in a monogamous relationship as long as the poz person has a clinically undetectable load, the risk to the neg partner is as near to zero as possible.

Finally, as indicated above, other drugs for PrEP are in the pipeline: don't fall into the trap of thinking PrEP=truvada, because while that might be so today, it probably won't tomorrow. Truvada is simply the first drug to have proven it can do the job.

hahaha, yeah I am aware of all of this.  I pretty much come here for the info that people wont readily tell me in the medical community.  

One thing I really hope is pushed through the approval pipeline is long acting injectable drugs.  Not just for PrEP but for HIV treatment as well.  IMO that could be the single biggest breakthrough in stopping HIV. 

[bttmsubslut]

I miss sometimes too, but I try really, really hard not to. I set my phone alarm for the same time every day. That helps. But sometimes it goes off and I don't have a pill on me. I try to remember to take it as soon as I can. But sometimes I lose track of time or I forget....