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HIV-ASSIST for Trainees
Simplifying Complex ART Switch Choices—The Perfect Opportunity to Introduce Trainees to HIV-ASSIST

Released: June 21, 2023

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Key Takeaways
  • HIV-ASSIST integrates multiple clinical considerations—with evidence and education in one platform—to identify effective and tolerable switch options for ART regimens.
  • HIV-ASSIST can be a valuable educational tool for trainees, enabling them to learn the rationale and evidence supporting preferred ART regimens.

As HIV healthcare professionals, we are expected to prescribe well-tolerated antiretroviral therapy (ART) regimens that effectively suppress HIV-1 RNA. But patient circumstances may change, and we must consistently review potential adverse events or issues related to the tolerability of their ART regimens. In a busy clinical environment where time for clinical review of patients is limited, ensuring a safe switch of ART for patients with virologic suppression can be challenging. Switches must be carefully planned by considering patient-specific clinical characteristics and preferences, available ART regimens, and existing guidelines. This is especially challenging for trainees who have less experience with ART and may have difficulty navigating clinical guidelines while balancing other responsibilities.

HIV-ASSIST can help healthcare professionals and trainees integrate multiple clinical considerations and identify the best ART regimens for individual patients. Of note, the HIV-ASSIST platform provides a wealth of educational information that explains the rationale behind each ART regimen it recommends, connecting directly to relevant evidence, guidelines, and clinical databases such as the Stanford HIV Drug Resistance Database and the University of Liverpool HIV Drug Interactions Checker. This tool provides quick and easy access to comprehensive information for learners.

Patient Case
Consider a 59-year-old person living with HIV who has achieved full viral suppression; has a history of IV drug use, alcohol overuse, previously treated hepatitis C, and newly diagnosed hypertension; and presents with reflux and hematemesis. Current medications include losartan, furosemide, aspirin, alprazolam, and methadone. You decide a proton pump inhibitor (PPI) is needed.

The patient has no known HIV drug resistance mutations and for several years has been fully suppressed on a regimen of rilpivirine (RPV)/emtricitabine (FTC)/tenofovir alafenamide (TAF). Previous regimens include dolutegravir (DTG) + abacavir (ABC)/lamivudine (3TC), but he was switched to the current regimen because of gastrointestinal discomfort.

For this patient with a new comorbidity and comedication, you decide an ART switch is necessary because of a drug‒drug interaction between RPV and the PPI. HIV-ASSIST can help suggest a reasonable switch strategy with the objective of facilitating adequate treatment of comorbid conditions, minimizing adverse events, and improving quality of life while maintaining virologic suppression.

After inputting the relevant data into HIV-ASSIST, we see that the top regimens in the output include combinations such as bictegravir (BIC)/FTC/TAF (Figure 1).

Figure 1. HIV-ASSIST output options for ART switch in a patient with a new comorbidity.

The rationale behind the proposed regimens can be viewed in the “Report” tab (Figure 2), where the weighted score is detailed for BIC/FTC/TAF: It favors this 1-pill regimen but penalizes it slightly for its larger pill size.

Figure 2. HIV-ASSIST scoring report for preferred regimen option.

By clicking on the listed regimens, an education sheet explains the rationale and evidence behind this choice of 1 integrase strand transfer inhibitor combined with 2 nucleos(t)ide reverse-transcriptase inhibitors (Figure 3), including evidence of a high resistance barrier.

Figure 3. HIV-ASSIST education sheet for selected regimen.

Clicking on the “Additional Information” tab and then on “Co-medication Warnings,” HIV-ASSIST provides information on possible drug interactions based on recommendations from guidelines and the Liverpool HIV Drug Interactions Checker. The interactions described between RPV and many of the patient’s current medications (pantoprazole, in particular) explain the rationale for switching the ART regimen (Figure 4).

Figure 4. HIV-ASSIST drug‒drug interaction explanation.

Educational Value of HIV-ASSIST for Trainees
Although the HIV-ASSIST platform is helpful for healthcare professionals with all levels of experience, the tool may be especially useful for trainees. Management of HIV is complex, and trainees’ rotation blocks often are too short to provide comprehensive training on all facets of care. Referral to dense guidelines is an inefficient method to obtain a quick answer regarding the management of an individual patient.

HIV-ASSIST, by contrast, is available both on computers and via a smartphone app—making it easily accessible for trainees. The platform’s design helps increase learners’ awareness of the important reference tools on which its recommendations are based. I find that the tool’s clear summary of information from these resources helps the learner understand when each resource is applicable for use in various clinical scenarios.

If preceptors are concerned about trainees using the tool as a shortcut, they may prefer a hybrid approach that incorporates standard resources, adding HIV-ASSIST in certain instances to provide a global and contrasting view of the available options. For example, traditional training with the source guidelines could be used for new ART initiation, whereas HIV-ASSIST could be used in more complex switch cases. To me, infectious disease/HIV preceptors should consider incorporation of the tool into their routine teaching for all levels of trainees.

Your Thoughts?
How do you perceive HIV-ASSIST as best providing educational support in your training and clinical setting? Please join the conversation by posting a comment below.