Q and A

Question

Add etravirine to Genvoya – NOT RECOMMENDED

I was diagnosed with acute HIV-1 infection in May 2017. My viral load was 10 million and my CD4 was 160. I started treatment with Genvoya and after five months of treatment, my viral load dropped to 99 copies and that of my partner to 220. My Cd4 is now 312.

The problem is that my physician said that he is afraid that we will develop resistance because during the last 2 months the decrease in the viral load was too slow. My partner’s viral load decreased from 270 to 220 copies only and my viral load increased from 78 to 99 copies.

Knowing that in the first two months the decrease was dramatic (from 10 millions to 200 copies) He prescribed etravirine with Genvoya to boost the treatment effect for the few coming months. I am afraid of taking Genvoya and etravirine together.

Please advise me if I can take them together and whether if it would be safe to stop etravirine when my physician recommends and to stay on Genvoya?

Answer

Thanks for emailing your question – and I hope you get to read this online reply.

First, and even without more details, please tell your doctor that there is a serious drug interaction between Genvoya and etravirine that means these drugs should not be used together.

Etravirine can reduce the booster in Genvoya and this in turn would reduce drug levels of elvitegravir (one of the main active drugs).

Please ask your doctor to check this online at:

http://www.hiv-druginteractions.org

Secondly, it is very common that starting with a very high viral load often takes longer that 3-6 months to reach undetectable levels. It is strange that you almost got this low though, but it is probably better to keep on your current combination and just check viral load more frequently – ie every month.

There is technically no difference between a viral load of 78 and 99 copies/mL and the test often is less sensitive at these levels.

Also, are you taking Genvoya with food? Even with the booster in Genvoya, food is still essential to get to high enough drug levels. Taking it with food now could be enough to get you to undetectable, if you were not always taking it with food before.

If your doctor is really worried abut drug resistance, or if the next viral load test in much higher (ie above 200 copies/mL), you could change to an anew combination where drug resistance is more difficult. This would mean using a combination based on dolutegravir rather than elvitegravir.

Depending on high high viral load becomes, this might mean using dolutegravir as a twice-daily dose (rather than once-daily).

Definitely do not start taking the etravirine though – and please let us know what you decide to do.

How is your partner doing too?

6 comments

  1. Simon Collins

    Hi Jacqueline,

    Before I reply to you main question about stopping, it would help to understand why you didn’t like treatment.

    If this was related to side effects, it would be easier to try a different combination. For example, a pill that doesn’t include a “booster” might be much easier.

    If your reason was more related to the psychological response to taking a pill every day, there are lots of ways to get support for this.

    Although guidelines are clear now that HIV treatment will benefit everyone, even with a high CD4 count about 500, the short-term risks from HIV are still very low when your CD4 count is this low. As the person taking treatment, you can of course always decide whether or not to be on medication.

    Please talk to your doctor though so they understand how you feel and that you have stopped.

  2. Jacqueline

    Ive was taking Genvoya for two months and i have stopped… I hate medication… I have CD4 700 but I dont know my viral load… I live in Greece and viral load test isn’t available… Can I live without meds and just keep testing my CD4 levels?

  3. Lisa Thorley

    Hi James,

    Ideally a persons viral load should become undetectable within three months. However, this isn’t always the case. This is because we’re all different. For example someone can start treatment with a viral load in the millions and be undetectable within a month or two. Someone else can start treatment with a viral load of say, 100,000 and it can take 6 months. Mine was like that.

    A persons life expectancy has nothing to do with how quickly their viral load decreases. Its to do with being on ARVs, and to a certain extent, just like it is for others who are negative, luck.

  4. James

    First I would like to thank you for your prompt reply. In fact the medicine my physician wanted to add to genvoya was a sample he provided me with (in the intention of helping me) on which the following was written: “Unlicenced medical product TMC125 100 mg Janssen R&D Ireland”. Isn’t it Etravirine? I was afraid of taking it with genvoya and I didnt let my partner to take it too. After your valuable advise, we decided to continue on Genvoya and to keep testing our viral load on a monthly basis. But the ” maximum of 6 months to get undetectable” is stressing us especially that I have read many studies about the relation between reaching undetectable load in 6 months and the survival rate…is that serious?

  5. Simon Collins

    Hi James, thanks for the feedback and new information.

    TMC125 was the development name for etravirine – many years ago. If there is an expiry date n the packaging I would expect this to be well out of date. Either way, it is good that neither of you used this.

    Proton pump inhibitors (PPIs) have no impact on your CD4 count but do interact with some HIV meds (especially ataznavir). Neither esomeprazole (Nexium) nor ranitidine interact with the meds in Genvoya though. The easiest way for you or your doctor to check is to use this online resource:
    http://www.hiv-druginteractions.org

    Desvenlafaxine (Pristiq) in not included in the table but your pharmacist should be able to confirm that an interaction is unlikley.

    Finally, there are lots of reports when very high viral load takes longer than 6 months to become undetectable. This is thought to be explained by having a larger reservoir of sleeping cells. Adding more drugs doesn’t seem to make much difference – it just takes time for the reservoir to be slowly reduced. At “almost undetectable” levels – ie less than 200 copies/mL – the risk of developing drug resistance are pretty low.

  6. James

    First I would like to thank you for your prompt reply. In fact the medicine my physician wanted to add to genvoya was a sample he provided me with (in the intention of helping me) on which the following was written: “Unlicenced medical product TMC125 100 mg Janssen R&D Ireland”. Isn’t it Etravirine? I was afraid of taking it with genvoya and I didnt let my partner to take it too. After your valuable advise, we decided to continue on Genvoya and to keep testing our viral load on a monthly basis. But the ” maximum of 6 months to get undetectable” is stressing us especially that I have read many studies about the relation between reaching undetectable load in 6 months and the survival rate…is that serious?

    Moreover, I have 2 other questions:
    A) For my case : the last 3 months I had reflux symptoms and I started taking Nexium 40 twice a day for few weeks then i reduced it to Nexium 20 twice a day. And after that I decided to switch to H2 receptors (Apo Ranitidine 150mg) twice a day because I have read a study about the impact of PPI on decreasing the cd4 count on long term.
    A.1- Does PPI affect Cd4 count?
    A.2- is it possible that the fact that I took PPI and now ranitidine was behind the slow down of the decrease in my viral load? Knowing that I still feel some reflux symptoms on ranitidine (Nexium was better in treating my reflux).

    B) concerning my partner’ case:
    He has been taking pristiq 50mg for mood control since 2 years could pristiq be behind slowing down the decrease in his viral load after 5 months of treatment? Knowing that his cd4 count is good (580)

    Finally, I know that we had a very highviral load at the diagnosis (5 months ago) as I told you in my previous message, but all the data on internet says that most of people get undetectable in less than 6 months . This why I am bothering you by all my questions.

    Thank you in advance.

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