Ask the Doc: Single Pill HIV Regimens

In this edition of Ask the Doc, Dr. Howard Scheiner answers questions about single-pill regimens verses three-pill cocktails that include a protease inhibitor. Although single-tablet regimens have been around for a while, a brand new pill is awaiting FDA approval, but it may not be right for everyone. If a single pill regimen is right for you, it may also be good news for your wallet.

One Pill Verses Three

Q: Dear Doc,

I just found out that I turned HIV-positive and my doctor is recommending medication immediately with three pills daily. This has me pretty depressed. I have friends taking one pill a day and I hear that a new once daily pill is coming out soon. Should I wait for that before starting treatment?

A: On October 22, 2013, ViiV Healthcare submitted a new drug application to the Food and Drug Administration for a single tablet combination of dolutegravir, abacavir and 3TC, known as Trii. You can get these meds already as Tivicay (dolutegravir) and Epzicom (abacavir/3TC), which are currently available. But that means two pills a day.

Approval should be coming soon for the single pill containing these meds, which may be superior in many ways to the existing single tablet regimens, especially for patients with other medical problems like depression or kidney problems. Also it can be taken with or without food. It has a high barrier to resistance (less likely to fail) and few interactions with other drugs. But like most everything else in life and medicine, it's not for everyone.

Chances are your doctor was recommending a protease inhibitor regimen requiring three tablets a day. There are no single pill regimens containing a protease inhibitor yet.

Your doctor may have chosen that because you have resistance to other classes of meds (NNRTI's or INSTI's) or sometimes before resistance testing has come back if he felt you needed to start treatment right away because you had a very low T-cell count or an opportunistic infection.

All patients should have resistance testing at the time of diagnosis to guide treatment. In addition, you need a blood test for HLA B5701 that predicts hypersensitivity to the abacavir component of Epzicom, (in which case it can't be prescribed).

Check with your doctor to be sure this was done and to find out if any of the current single tablet regimens or the two-tablet regimen of Tivicay/Epzicom is right for you, while you await Trii approval.

Cut Costs By Cutting Pills

Q: I am paying too many co-pays for my HIV meds. I take three different pills a day and would like to take just one. What do you suggest?

A: The first suggestion is to ask your doctor if you can switch to one of the single pill combinations that are available. There are many things that could limit this type of switch.

Neuropsychiatric conditions like depression, the need for certain medications for acid reflux or underlying kidney abnormalities can all argue against a single pill. If you require a protease as part of that combo, you will have to wait.

On the horizon, there is an application for Reyataz (atazanavir) and cobicistat together which will cut down on one co-pay, but it will still need to be taken with one other pill (the backbone). On the more distant horizon, there is a protease single pill regimen in clinical trials with darunavir-cobicistat-TAF-FTC.

Basically this is Prezista, a protease, with a precursor drug to tenofovir, called TAF (tenofovir alafenamide), which causes less bone loss and kidney abnormalities. Tenofovir is part of all the single pill combos currently available.

Called "more than a doctor, a trusted friend" by his patients, Dr. Howard Scheiner is a true native New Yorker. He was born in the Bronx, he attended the esteemed Bronx High School of Science and City University of New York before receiving his medical education at The Mount Sinai School of Medicine. Truly a Renaissance man, in addition to his lifelong service to the medical profession, Dr. Scheiner is a published author, playwright and musical composer. Combining all his loves, he is perhaps most proud of founding "The Brent Varner Project, Inc." a charity that provides free HIV services to those in need through the Actors Fund of America.

This story is part of our special report: "Ask the Doc". Want to read more? Here's the full list.

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