A United States HIV provider survey of antiretroviral therapy management in people living with HIV with co-occurring conditions

TL;DR

This study explores how US HIV providers adjust antiretroviral therapy for patients with HIV and other health conditions, showing that treatment choices often differ from standard guidelines.

Contribution

The study provides new insights into real-world ART selection strategies for HIV patients with co-occurring conditions in the US.

Findings

Bictegravir/tenofovir alafenamide/emtricitabine was most commonly prescribed for cardiometabolic disease cases.

Dolutegravir-based regimens were preferred in pregnancy scenarios, though some providers used bictegravir/tenofovir alafenamide/emtricitabine.

Providers often switched regimens for weight gain and renal disease, using lamivudine or emtricitabine in fixed-dose combinations.

Abstract

Simplified HIV treatment guidelines favor integrase strand transfer inhibitors (INSTIs). However, non-infectious comorbidities and co-occurring conditions (i.e. pregnancy) often necessitate individualized antiretroviral therapy (ART) regimens. This study aimed to characterize United States HIV provider strategies for ART selection when faced with concomitant health conditions.

A survey of US HIV providers was conducted using hypothetical patient cases. Standardized clinical case-vignettes were developed and providers were asked to select their preferred regimen. Eleven cases focused on cardiometabolic syndrome, renal dysfunction, weight gain, and pregnancy.

119 providers responded across all cases (with a median 57 responses [interquartile range 55.5–72] per case), and were primarily Infectious Diseases physicians in academic settings from across the continental United States. Bictegravir/tenofovir alafenamide/emtricitabine was most commonly prescribed for three case-scenarios of cardiometabolic disease (62.3%). Diverse regimens were recommended for a case involving weight gain, with 98.5% switching from dolutegravir plus tenofovir alafenamide/emtricitabine, most commonly to doravirine/tenofovir disoproxil fumarate/lamivudine. Dolutegravir-based regimens were selected in case-scenarios of pregnancy (77.3%), with some use of bictegravir/tenofovir alafenamide/emtricitabine (13.6%). For two case-scenarios renal disease with worsening creatinine clearance to < 30 mL/minute, many providers used lamivudine or emtricitabine in fixed-dose combination (43.3%).

This study reveals varied ART approaches for people living with HIV and non-infectious conditions, often diverging from standard regimens. While guidelines provide a framework, providers adapt treatment based on patient needs. Further research is crucial to optimize ART management in these complex situations.

The online version contains supplementary material available at 10.1186/s12981-025-00724-w.

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