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HIV Treatment Guidelines

February 13, 2017

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What to Start With?

Once you have decided to start treatment, you and your health care provider need to choose what combination of drugs you are going to take. No single HIV drug should ever be used by itself, though often several HIV drugs are combined into one tablet or combination pill. HIV drugs work in different ways to stop the virus at different points in its lifecycle. The drugs are divided into classes as follows:

  • Nucleoside/nucleotide reverse transcriptase inhibitors ("nukes" or NRTIs)
  • Non-nucleoside reverse transcriptase inhibitors ("non-nukes" or NNRTIs)
  • Protease inhibitors (PIs)
  • Integrase inhibitors
  • Entry inhibitors (which includes fusion inhibitors and chemokine receptor 5 (CCR5) antagonists)
  • Boosting agents

Your first treatment regimen will probably contain:

  • An integrase inhibitor plus 2 NRTIs or
  • A PI plus 2 NRTIs [the PI should be combined, or "boosted," with a small dose of a second PI called Norvir (ritonavir); this makes the first PI work better]

These combinations will attack HIV at different parts of its lifecycle to pack a strong punch against the virus.

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In the U.S., the DHHS guidelines rank specific drug combinations as recommended or alternative (see below). While the recommended regimens are the best choices for HIV treatment, they may not be ideal for everyone. Because everyone's situation is different, there may be cases in which alternative treatments are actually better for you. You and your health care provider should choose drugs based on your specific needs. Think about what will fit into your lifestyle, including dose schedule, number of pills, and side effects. Also consider what other medications you are taking, any other medical conditions you have, and the results of resistance testing (see below).

Whatever regimen you choose to take, you need to take your drugs on schedule. This is called adherence. In order to get the most benefit from HIV treatment, good adherence is required. This is because HIV drugs need to be kept at a certain level in your body to fight the virus. If the drug level falls, HIV may have a chance to fight back and develop resistance. Skipping doses, not taking the drugs on time, or not following food requirements can cause your drugs to be less effective or stop working altogether.

For more information on the different classes of HIV drugs and how they work, see our fact sheet on HIV Drugs and the HIV Lifecycle. For more information on individual drugs sorted by class see our HIV Drug Chart. Please note: for the regimens listed below, the brand name of an HIV drug is listed first and capitalized, with the generic name lower-cased and in parentheses. For example: Truvada (emtricitabine + tenofovir disoproxil fumarate).


U.S. DHHS Recommended Regimens

Study results of these combinations showed they were powerful and long-lasting, did not have a lot of side effects, and were easy to use. Recommended regimens include:

For people who have never taken HIV drugs before ("treatment naive"), regardless of baseline viral load or CD4 count:

Integrase inhibitor-based regimens:

  • Tivicay (dolutegravir) and Epzicom (abacavir + lamivudine)
  • Tivicay and Truvada (tenofovir disoproxil fumarate + emtricitabine)
  • Tivicay and Descovy (tenofovir alafenamide fumarate + emtricitabine)
  • Stribild (elvitegravir + cobicistat + emtricitabine + tenofovir disoproxil fumarate)
  • Isentress (raltegravir) and Truvada
  • Isentress and Descovy
  • Genvoya (elvitegravir + cobicistat + tenofovir alafenamide fumarate + emtricitabine)

Boosted PI-based regimen:

  • (darunavir) and low-dose Norvir (ritonavir) and Truvada or Descovy


WHO Recommended Regimens

The WHO guidelines suggest that first-line HIV therapy be a combination of an NNRTI plus 2 NRTIs. Specifically, they recommend either: (1) Atripla (efavirenz + tenofovir disoproxil fumarate + emtricitabine) or (2) Sustiva (efavirenz) + Viread (tenofovir disoproxil fumarate) + Epivir (lamivudine). These two regimens are also those recommended for women who are pregnant or breastfeeding.


Alternative Regimens

There are many alternative HIV treatment regimens that have been proven effective and tolerable and are approved by the DHHS and WHO. Which one might be right for you is based on your specific characteristics and needs and is best discussed with your health care provider.


Regimens for Pregnant Women or Women Who Plan to Become Pregnant

Guidelines on taking efavirenz (brand name Sustiva; also found in Atripla) during early pregnancy remain conflicted. The U.S. Department of Health and Human Services' July 2016 guidelines suggest that:

  • women who wish to become pregnant should not take efavirenz because it may cause birth defects when taken during early pregnancy
  • taking efavirenz appears safe after eight weeks of pregnancy
  • women who are successfully virally suppressed on a treatment regimen containing efavirenz who become pregnant can continue on efavirenz throughout pregnancy

The World Health Organization (WHO)'s guidelines, however, suggest that efavirenz can be taken throughout pregnancy, including during the first trimester (12 weeks). The WHO's recommendations are based on a report in which researchers reviewed many different studies and found no connection between taking efavirenz during the first trimester of pregnancy and an increased risk of birth defects.

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Read the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (PDF)
More News and Analysis on HIV Treatment Guidelines


  
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This article was provided by The Well Project. Visit The Well Project's Web site to learn more about their resources and initiatives for women living with HIV. The Well Project shares its content with TheBody.com to ensure all people have access to the highest quality treatment information available. The Well Project receives no advertising revenue from TheBody.com or the advertisers on this site. No advertiser on this site has any editorial input into The Well Project's content.
 

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