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Optimized ART for All
All for ART Optimization and Optimized ART for All

Released: October 09, 2025

Michelle Cespedes
Michelle Cespedes, MD, MS
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Key Takeaways
  • Optimizing HIV care goes beyond achieving viral suppression; as people’s lives change, so too may the best ART regimen for them.
  • Every individual should be a candidate for ART optimization, even if their current regimen is effective and well tolerated.

Despite ongoing innovation in antiretroviral therapy (ART) development, sometimes healthcare professionals may not be confident in their ability to individualize ART for diverse people living with HIV.

I think optimizing HIV care goes beyond achieving viral suppression. As people’s lives change, so too may the best ART regimen for them. The following 2 patient cases clearly demonstrate, to me, the importance of individualizing ART in contemporary HIV care.

37-Year-Old Woman
The first case involves a 37-year-old woman whose HIV was well controlled on darunavir/cobicistat/tenofovir alafenamide (TAF)/emtricitabine (FTC), with a CD4 count of 530 cells/uL. She was recently diagnosed with psoriasis and was interested in coming off birth control, with the goal of trying to conceive with her husband of 3 years.

She had been diagnosed with HIV during her pregnancy 7 years ago and started a boosted protease inhibitor (PI) regimen to prevent vertical transmission, considering safety concerns regarding integrase-based regimens at the time. Her ART regimen was subsequently simplified to a single-tablet PI-based regimen once it became available.

She mentioned that her mom had a heart attack at age 57, and she was surprised to learn that psoriasis can be associated with increased risk for cardiovascular disease. Her psoriasis was considered mild to moderate, and her rheumatologist was considering the use of a biologic for treatment that would be considered safe in pregnancy.

In the meantime, she had been doing some reading on her own and was interested in simplifying her ART regimen to one that has the lowest potential for drug–drug interactions, is safe in pregnancy, and is not associated with cardiovascular disease.

Truly Patient-Centered Treatment
This case highlights the importance of having a discussion and being aware of the fertility desires of our patients of childbearing potential. I had a patient-centered discussion with her reiterating that the most important thing was for her HIV to remain undetectable once she became pregnant in order to prevent mother to child transmission. I explained my rationale for recommending a switch to an integrase-based single tablet regimen that did not include cobicistat, to avoid possible drug–drug interactions with future treatments for her psoriasis.

Despite safety data supporting long-acting (LA) cabotegravir (CAB) in pregnancy for pre-exposure prophylaxis (PrEP) and rilpivirine in pregnancy for treatment, I did not recommend switching to the combination of LA CAB + rilpivirine because I’d like to see more extensive data on the use of the combination during pregnancy. And despite the theoretical increased risk of cardiovascular disease with her newly diagnosed psoriasis, I also did not start a preventative statin, given her age and possible impending pregnancy.

This case illustrates the many considerations that an individual might have despite having well-controlled HIV on a well-tolerated ART regimen: potential pregnancy, familial cardiovascular disease, and possible drug–drug interactions.

At first glance, she may not appear to be a strong candidate for ART switch. There was nothing wrong with her current ART regimen, but that may change as her circumstances change or as she initiates new treatments for existing conditions.

42-Year-Old Man
The next case involved a 42-year-old man whose HIV was well controlled on bictegravir (BIC)/TAF/FTC, with a CD4 count of  530 cells/uL. His viral load was already undetectable on BIC/TAF/FTC when he transferred to my practice 6 years ago. He was unable to remember which ART medicines he was on before his current regimen, and none of his previous health records were available.

He had been considerably overweight his entire life and was even diagnosed with prediabetes, with his A1C getting as high as 5.8% 2 years ago.

He was particularly excited to show off the 45-pound weight loss he achieved over the last 8 months. He accomplished this through use of a GLP-1 that was prescribed by his primary care provider, who was unaware of his HIV. With the weight loss, he made several lifestyle modifications and intended to continue his diet and exercise routine.

He was highly motivated to not regain the weight and was interested in switching away from his current HIV regimen, which he heard is associated with weight gain. He reiterated that he did not want to increase his pill burden and reminded me that increased pill burden was 1 of the reasons he declined starting a preventative statin, despite the benefits demonstrated in REPRIEVE data last year.

Upon further discussion, he revealed that he was treated for syphilis and asymptomatic rectal chlamydia 3 months ago. He was also treated for acute hepatitis C 4 years ago after previously screening negative. He had been vaccinated for hepatitis B when he was initially diagnosed with HIV 12 years ago.

To Switch or Not to Switch
I had a patient-centered discussion with him focusing on his concerns and discussed at length ways to mitigate his risk for acquiring sexually transmitted infections (STIs). We discussed how the data regarding which ART may be contributing to weight gain have not been consistent through different switch studies or clinical trials or subgroups. Overall, to me the data do not support clinically significant weight loss with switch to alternate regimens.

I explained that diet modification and consistent exercise would probably be the most helpful interventions to prevent significant weight gain, which he was already doing. I also explained that the contribution of weight management and overall health benefits of the GLP-1 that he is already using has not been studied extensively in people living with HIV.

I provided an update on recent data for the use of on-demand DOXY PrEP in those who have ongoing risk of acquiring preventable STIs. I encouraged him to reconsider making his primary care provider aware of his HIV status and any medication changes.

Like the first individual, this person’s ART regimen was working for him in controlling his HIV, but he had questions about whether it was negatively affecting his health in other ways, such as weight gain. We discussed considerations such as changes in weight, modified cardiovascular risk with use of a GLP-1, and continued risk for STIs.

Another consideration was that his previous antiretroviral regimens were unknown. Individualizing ART for treatment-experienced people with HIV may seem daunting but is now more possible than ever, considering the array of highly effective modern regimens we have at our disposal.

Your Thoughts?
Ongoing innovation in ART development has moved HIV care leaps and bounds beyond just control of viral replication. People living with HIV now can expect to achieve the desired clinical endpoints of successful therapy with an optimized regimen that fits their individual needs and preferences, and that induces few to no adverse events or drug–drug interactions. How do you balance prioritizing virologic suppression with patients’ other health concerns?

My colleagues Tristan Barber, MD, and Monca Ghandhi, MD, will be exploring clinical scenarios like these in detail at our upcoming symposium, with discussion of how evidence-based data and clinical experiences have guided us as we optimize and individualize ART. To learn more, join us for our lively interactive discussion either online or in person in Atlanta: Register now!

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