Treatment Regimen for HIV Patient with Resistance to Rilpivirine and Tenofovir

Understanding the Patient's Situation

• The patient has documented resistance to rilpivirine and tenofovir, indicating multiclass drug resistance 1, 2
• The patient prefers non-oral HIV medications, suggesting potential adherence challenges with daily oral regimens 1, 3

Why Cabotegravir/Rilpivirine (Cabenuva) is Contraindicated

• Patients with documented resistance to rilpivirine should not receive Cabenuva (cabotegravir/rilpivirine) due to increased risk of treatment failure 4

Appropriate Injectable Treatment Options

• Lenacapavir (administered every 6 months) is recommended for patients with multiclass drug resistance, including resistance to NNRTIs like rilpivirine 1, 2, 5
• For patients with extensive multiclass resistance, agents with novel mechanisms of action such as lenacapavir are recommended, ideally in combination to allow for 2 fully active drugs (evidence rating: AIa) 2, 5

Treatment Algorithm for This Patient

• Confirm resistance patterns through comprehensive resistance testing while the patient is on the current failing regimen 6
• Use lenacapavir (every 6 months) as the backbone of the injectable regimen 2
• Consider adding another fully active agent with a different mechanism of action 2
• Continue treatment with NRTIs that retain partial activity even in the presence of resistance mutations (evidence rating: AIIa) 2

Monitoring

• Check viral load one month after switching regimens 6
• Continue monitoring viral load every 3 months for the first year 4
• Monitor for potential adverse effects of the new regimen 6

Important Considerations and Caveats

• Virologic failure with inappropriate use of Cabenuva can lead to development of resistance to both integrase inhibitors and NNRTIs, further limiting future treatment options 4
• For patients with poor adherence to oral medications, intensive case management and adherence support should accompany injectable regimens 1, 2