Î The DHHS Panel on Antiretroviral Guidelines for Adults and
Adolescents recommends the following as regimens for antiretroviral
(ARV)-naive patients (listed in alphabetical order unless otherwise
indicated):
a
Preferred:
NNRTI-Based Regimen
• EFV/TDF/FTC (AI)
PI-Based Regimens
• ATV/r + TDF/FTC (AI)
• DRV/r + TDF/FTC (AI)
INSTI-Based Regimens
(in order by drug approval)
• RAL + TDF/FTC (AI)
• TDF/FTC/EVG/COBI
c
(AI)
• DTG + ABC/3TC (AI)
• DTG + TDF/FTC (AI)
Î Other regimens ("Acceptable regimens," "Regimens that may be
acceptable but more definitive data are needed," "Regimens that may
be acceptable but should be used with caution," and "Antiretroviral
regimens or components that should not be offered at any time") are
shown in Tables 3 and 4.
Î Virologic failure is now defined as the inability to achieve or maintain
suppression of viral replication (to an HIV RNA level <200 copies/mL).
Î Genotypic testing is recommended as the preferred resistance testing
to guide therapy in patients with suboptimal virologic responses or
virologic failure while on first or second regimens (AIII). Addition
of phenotypic testing to genotypic testing is generally preferred for
persons with known or suspected complex drug resistance mutation
patterns, particularly to protease inhibitors (BIII).
Î Treatment Goals
• Reduce HIV-associated morbidity and prolong the duration and quality of
survival,
• Restore and preserve immunologic function,
• Maximally and durably suppress viral load, and
• Prevent HIV transmission.
Key Points
a
Evidence from randomized clinical trials supporting a benefit of ART is not available. However, support for
earlier therapy is based on:
(1) A report from at least one recent cohort study demonstrating survival benefit with initiation of
ART at CD4 count >500 cells/mm
3
;
(2) Growing awareness that untreated HIV infection may be associated with development of many
non-AIDS-defining diseases, including cardiovascular disease, kidney disease, liver disease, and malignancy;
(3) Greater efficacy, convenience, tolerability, and safety of current antiretroviral regimens; and
(4) Increasing evidence that effective ART reduces HIV transmission (BIII).
b
Only in patients with pre-treatment HIV RNA ≤100,000 copies/mL (BI).
c
With pre-treatment CrCl ≥70 mL/min (BI).
Alternative:
NNRTI-Based Regimens
• EFV + ABC/3TC (BI)
• RPV/TDF/FTC
b
(BI)
• RPV + ABC/3TC
b
(BIII)
PI-Based Regimens
• ATV/r + ABC/3TC (BI)
• FPV/r (daily or bid) + (ABC/3TC or
TDF/FTC) (BI)
• LPV/r (daily or bid) + (ABC/3TC or
TDF/FTC) (BI)
• DRV/r + ABC/3TC (BIII)
INSTI-Based Regimen
• RAL + ABC/3TC (BIII)
