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Initiating HIV/AIDS Therapy in Treatment-Naïve Patients
Are TDF/FTC AND ABC/3TC the new gold standards for backbones?
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Dr. Wohlfeiler (OC): I think that to a large extent that is true. As I mentioned, I think there is a push for once a day medications. These are both once a day. They are both potent and well tolerated combinations.
So I think that as far as nucleoside backbones go, those are the two combinations. And obviously there's a preference I think to fixed dose combinations, both in terms of adherence, and also a big issue in our patients nowadays is the issue of copays. Copays have become so expensive for patients with private insurance that if they can pay one copay instead of two copays it often is a really critical issue for them.
These fixed dose combinations are important. And I really do think that those two combinations are the ones that we're really seeing as the preferred nucleoside backbones.
I think that the two fixed dose combinations of tenofovir FTC and abacavir 3TC are really going to be the preferred backbones by virtue of the fact that they're once a day, they're potent, they're well tolerated, all those reasons.
Dr. Kwakwa (OC): I believe that the choice will be driven not only by initial toxicity, but also by long-term toxicity, and that really I think is one point of difference between the two of them, where the main toxicity concern with abacavir/3TC is the potential for abacavir hypersensitivity reaction, which is certainly a short-term concern, whereas the main concern for tenofovir may be the potential renal toxicity, which is a long-term concern, as long as the patient remains on the drug, pretty much. So I think that's a big point of difference between the two main toxicities of the two drugs.
If I may add one other issue that I think distinguishes them, one from the other, it is the potential for drug-to-drug interactions. I think that that certainly does distinguish them as well.
Dr. Wohlfeiler (OC): What I find amazing is that it used to be that with our patients with private insurance they had access to medications and everybody was able to get them. And it wasn't an issue. And now I've got patients with insurance plans where the copays have increased to as much as $70 per medication. Since none of the HIV medications, or virtually none of them, are generic at this point, I've got patients who are spending $300, $350 a month just in copays for their antiretrovirals and certain other medications that they need to be on.
And so what we're finding is that increasingly patients with private insurance aren't able to get their medications because they can't afford copays.
I'm Medical Director of a big Ryan White program here, and Ryan White is a payor of last resort and really intended for patients who had no coverage at all. And what we're finding is that we're having a huge influx of privately insured patients coming into Ryan White so that Ryan White can pick up their co-pays because they can't get their medications otherwise because they simply can't afford them. So it's a big problem. And that's the other reason why the fixed dose combinations become increasingly important.
DR. Kwakwa (OC): I think cost will affect our treatment decisions more and more as third-party payers, as the state ADAP system, become more and more underfunded. I think that some of these decisions may be taken away from us. I know that in some states, that is already happening, and so I see that playing a greater role, unfortunately, in the foreseeable future.
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