Ryan Haumschild, PharmD, MS, MBA: Let’s discuss the major unmet needs, some of the adherence concerns, and population health perspectives related to heavily treatment-experienced individuals with HIV. Mr Driffin, we can start with you. How do medication burden and stigma around medication use impact adherence rates and multidrug-resistant HIV?

Daniel Driffin, BS, MPH: I definitely think the interaction could be negative. I recently did a podcast with a colleague in public health, and he showed me a picture of 10,000 pills. It alluded to the number of pills I had taken over the last decade as a person living with HIV. He then wiped them all away, and they fell on the floor. It truly captured the moment of realizing that you’re tired of the pill burden. It’s a conversation we haven’t had, especially with our more marginalized patients: patients who are Black or brown, who may not speak English as their first language, who may use governmental assistance, or who may even be unhoused. [It’s still] stigmatized. Many of those same patients live in states where [aspects of living with HIV are] still illegal or criminalized. It all meets at that intersection around whether I’ll be motivated in the morning or at night to take this pill to be healthy. Being mindful of adherence toward multidrug resistance [MDR] is important.

Some of the solutions I’ve seen ensure that individuals living with HIV have some version of a support system, whether that’s a support group at their medical home, or even partnering with a case manager or a peer navigator at the medical home to ensure that you’re doing what you’re supposed to be doing. Some medical homes have a party at the end of the year to say great job, [so individuals] continue that success of staying undetectable. That’s the conversation, especially as we continue to gear up toward ending HIV by 2030, which is 1 of our national goals. All of that goes into this conversation. I hope I answered the question.

Ryan Haumschild, PharmD, MS, MBA: You did. That’s something we don’t celebrate enough: individuals maintaining their adherence and being able to stick to different regimens throughout their treatment journey. That’s important to highlight. You talked about some of the stigmas and the burden that I think is something that we have to navigate through. I’m going to turn it back to Dr Sension who’s actively treating patients. What are the biggest barriers to adherence in HIV and are there additional or more significant barriers for those patients with multidrug resistant HIV?

Michael Sension, MD: I mentioned it earlier, but it’s a complexity of regimens. It’s tolerability. What have we been able to see over the last 25 years? There were medications that were 3 times a day, and then they became twice-a-day regimens. There were regimens that were 18 pills. We were able to get down to 10 pills, 5 pills twice a day, then 3 pills twice a day, then coformulated products, and then 1 pill twice a day. Most recently we’ve been looking at 1 pill once a day. And the size of the pill went from a small egg to the size of a Tic Tac. That makes a difference.

Also, how does it make you feel? Do you have diarrhea? Do you have nausea every time you take it? Does it make you feel funky? Do you have wild and crazy dreams? Does it make you feel foggy? Or is it essentially like taking a placebo and you have very few adverse effects? Fewer pills, fewer times a day, fewer adverse effects have led to better adherence.

What are the challenges for multidrug-resistance individuals? In my patient population, they’re the ones who may not be on a 1-pill, once-a-day regimen. Even their OBR [optimized background regimen] may be twice a day or multipills twice a day. That’s a little more of a challenge. To the degree that I can look to see what class of medication they’re on, [we want to look] within the class if there’s something that could be smaller, taken fewer times a day, with fewer with effects. [Maybe there’s] a once-a-day dosing of a product they’re using together with a core agent that I could be adding that would be novel. Could I create something simple and doable?

Transcript edited for clarity.