Reduced-drug treatment becoming common in Paris

Almost half of people with HIV receiving care at one of Paris’s largest HIV clinics received antiretroviral regimens consisting of two drugs or intermittent treatment in 2022 and drug reduction strategies almost halved the cost of HIV care between 2015 and 2022, Dr Luis Sagaon-Teyssier reported at the 19th European AIDS Conference (EACS 2023) in Warsaw on Friday.

Drug reduction strategies are designed to reduce exposure to antiretroviral drugs. Two-drug regimens combining dolutegravir with either lamivudine (Dovato) or rilpivirine (Juluca) have proved to be as effective as three-drug regimens in suppressing viral load.

A French study has also investigated whether intermittent treatment – four days on, three days off – with a three-drug regimen is as effective as continuous treatment. The QUATUOR study found that the intermittent regimen maintained viral suppression as well as continuous treatment but with a slightly higher rate of virological failure after two years.

Another study presented at EACS 2023 last week found that a four-days-on, three-days-off schedule for taking two-drug therapy resulted in a higher frequency of virological failure and drug resistance in those who took intermittent treatment.

Drug reduction strategies are also attractive because they reduce medication costs. Antiretroviral treatment was the largest medication cost in the Paris region, costing 137 million euros in 2021.

To assess the adoption of drug reduction strategies, their impact on viral suppression and spending on antiretroviral treatment, the researchers looked at the evolution of treatment in people who were taking antiretroviral therapy in 2015 at the Pitié-Salpêtrière Hospital in Paris. The study followed 2288 people with HIV who had at least one clinic visit each year between 2015 and 2022, 78% taking three-drug treatment and 22% taking two-drug treatment at baseline.

Those taking two-drug treatment at baseline had been taking antiretroviral treatment for significantly longer (18.5 vs 11.5 years), were older (54 vs 49 years) and more often born in France (60% vs 47%).

Of those taking three-drug daily treatment in 2015, 43% had switched to two-drug or intermittent treatment by 2022 (23% to two-drug daily or intermittent treatment and 19% to three-drug intermittent treatment).

Of those taking two-drug daily treatment in 2015, 60% remained on it, 19% switched to two-drug intermittent treatment and 24% switched to three-drug treatment.

By 2022, half of all patients eligible for this analysis were taking reduced-drug treatment.

In people taking three-drug daily treatment in 2015, there was no change in the proportion who were virally suppressed in 2022, regardless of the treatment strategy they subsequently adopted. The same was true for people taking two-drug daily treatment in 2015.

Switching to a drug-reduced treatment strategy was more likely for people who were under the care of a full-time HIV physician, people born in France and people with suppressed viral load. Age, gender and duration of antiretroviral treatment were not significantly associated with drug-reduced treatment in a multivariable analysis.

Drug-reduced treatment strategies did not lead to an increase in patient consultations or viral load tests. Overall, drug-reduced treatment strategies were associated with a 29% reduction in drug costs and intermittent treatment strategies were associated with a 58% reduction in drug costs. However, it should be noted that the cost of all treatment strategies fell between 2015 and 2022, partially due to increased availability of generic versions of commonly prescribed drugs.