Question

Can I reduce the drugs I take?

31 January 2017. Related: All topics, Changing treatment, Resistance, Side effects.

I am 42 years old and been HIV+ since 1985. I have resistance to a lot of drugs that I have taken in the past but I have been undetectable since 2005.

My current regime is etravirine, raltegravir, Truvada and darunavir/ritonavir – it is all twice daily apart from the Truvada. I am switching Truvada to Descovy next week as being on Truvada for over ten years is causing osteoporosis and my kidney function is suffering badly. My tablet count is nine a day.

My appetite is up and down and have always struggled to maintain my weight. I am fed up of feeling nauseous and never enjoying food. I have looked at a French study that happened last year about doing four days of meds and three days off. Everyone who took part in this study remained undetectable.

Basically I am fed up of taking such a large dose of drugs everyday. I did have AIDS in 2004 and been undetectable without any blips since 2005. Why does a fully suppressed virus need to be hammered with such large doses of drugs everyday. People forget how toxic these drugs are long term. I feel that the least amount of drugs I have to take is obviously better for my body and long term health. Any advice of information would be welcome.

Answer

Answer: Simon Collins

Thanks for your email and for letting the answer be posted online. You ask many questions that other people might be interested in.

Although this answer discusses the general approach to reducing treatment, each person’s situation will be different. This means you need to talk to your doctor about advantages and disadvantages of these options for you.

Firstly, it is really good that your viral load has been undetectable for over ten years. This shows that even though you had drug resistance to some earlier drugs, your current combination is working well. This means your doctor might be nervous of changing anything, especially as you have some serious HIV related health problems a long time ago.

This doesn’t mean that you don’t have options to reduce treatment – and several recent studies have reported interesting results from doing this. It does mean that changing your combination needs to be done carefully, with extra viral load monitoring until your new treatment is stable.

Reducing meds covers three different approaches:

Reducing the numbers of meds in you combination – but still taking them every day.
Keeping on the same combination, but taking meds on fewer days each week.
Using reduced doses of some meds

Each of these approaches are based on very limited study results – usually small studies. Even though these results sound promising, larger studies are needed before either approach will become widely recommended for most people.

For people whose current quality of life is not good because of side effects, both approaches are important to know about.

1. Reducing numbers of meds

For more than twenty years, researchers have looked at whether you can use one combination to get viral load to undetectable, and another to keep it this low. In general, most of these studies were not successful: three drug combinations are needed.

Using boosted PI monotherapy (ie without other meds) was the most successful of these strategies. The only PI now recommended for this is boosted darunavrir. However, in the UK PIVOT study about one in three people had low level viral load blips – so without additional monitoring this approach is not recommended.

More recently, very interesting results were reported using the integrase inhibitor dolutegravir. Unlike any other HIV drugs, dolutegravir might have properties that means it can be used either as monotherapy or just with lamivudine (3TC). While monotherapy is probably not a good idea for most people, adding the easy to tolerate drug 3TC is looking very interesting.

Until there are results from larger studies, if your quality of life is difficult on current treatment, this might be an option. This article reposts these studies:
https://i-base.info/htb/30918

Some of the people in the reduced dolutegravir studies we similar to your situation. Many had been HIV positive for many years with previous drug resistance and they had difficulty with treatment. Of all the options, discussing whether dolutegravir plus 3TC might be an option might keep your viral load undetectable and improve your quality of life.

2. Taking meds on fewer days each week

Again, reducing the number of days that you take meds each week has been a research focus for many years.

The more successful results was related to the specific combination of efavirenz/tenofovir-DF/emtricatabine (Atripla). After daily dosing for several weeks or months, these three meds all reach good drug levels that generally stay high inside cells for more than 1-2 days. This is not the case for other HIV meds though, especially any drug that needs to be taken twice-daily).

In the FOTO study (Five On, Two Off), taking Atripla for only 5 days a week achieved the same results at taking Atripla on every day. Over one year, there were no viral load blips in people who stopped Atripla at the weekend.

This article looks at taking Atripla on only three days a week might work:
https://i-base.info/htb/30601

Other combinations are more difficult to recommend for this approach – but this study includes using other combinations four days a week:
https://i-base.info/htb/30633

3. Reducing drug dosing

This is probably the most cautious approach – and is also limited to only a few drugs, mainly efavirenz. A few studies have suggested that instead of using a 600 mg daily efavirenz dose, reducing this to 400 mg a day might be just as effective.

Reducing the dose of other HIV meds is definitely NOT recommended though, as this could easily lead to drug resistance.

In summary, if you try doultegravir plus 3TC, additional viral load would be needed. Although dolutegravir has fewer side effects than most HIV meds, some people get disorientated and mood changes that mean they switch to alternatives. If you and your doctor decide to try this and there are problems, you could always return to your current treatment.