Treatment of Drug Resistant HIV

28/M, comes to clinic for a new dx of HIV on routine testing a few months ago. Prior HIV tests were neg. He recently moved to the US from the Philippines & has been taking entevacir for HBV x 8 yrs. Which of the following HIV mutations can be expected in his HIV genotype?
A. K103N
B. K65R
C. I50L
D. M184V

The majority got the right answer, M184V mutation.
Entecavir, an HBV polymerase inhibitor, has been shown to have activity against HIV. Entecavir monotherapy for HIV has been shown to cause the development of HIV M184V mutation

In people with HIV/HBV co-infection, TDF or TAF in combination with FTC is the preferred backbone for ART. TAF/FTC is generally preferred if CrCl 30-50.

The use of entecavir to treat people with HIV/HBV co-infection is usually entertained in the setting of renal failure (CrCl <30). In this situation, options include:
▪️Renally-dosed entecavir
▪️Renally-dosed TDF
▪️Switch to TAF/FTC/COBI/ELV

TAF/FTC/COBI/ELV, has been shown safe/effective in people with ESRD on HD There is also limited but promising data on the safety and efficacy of TAF/FTC/BIC also in people with ESRD on HD

If entecavir is to be used to treat people with HIV/HBV co-infection:
▪️Patient on a fully suppressive ART (VL <20)
▪️Consider an NRTI-sparing regimen (theoretical risk of ⬆️ entecavir resistance)

Note that ART regimen with 3TC or FTC as sole anti-HBV tx is not recommended due to the high risk of developing HBV 3TC- resistance (20%/year).

Not recommended for HIV/HBV co-infection (lack of robust data, increased toxicity, higher tx failure): adefovir (higher rates of renal failure), telbivudine (higher rates of myopathy/neuropathy).

@ID_fellows @NNolanMD @LeMiguelChavez @swinndong @TxID_Edu @JonathanRyderMD

Originally tweeted by WuidQ: Washington University ID Questions (@WuidQ) on 11 January, 2021.

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