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Antiretroviral Therapy in 2014: How Does a Doctor Choose?

By Joel Gallant, M.D., M.P.H.

March/April 2014

Antiretroviral Therapy in 2014: How Does a Doctor Choose?

While development of drugs for HIV infection has definitely slowed over the last several years, treatment options continue to expand and improve, making antiretroviral therapy (ART) easier, better tolerated, and more convenient. In this article, I'll discuss my own opinions on options for initial therapy, and what's in the pipeline for treatment-experienced patients.

Initial Therapy

There's a wealth of potential options for first-line therapy, but only a few combinations that we should actually be using on a regular basis. Speaking for myself, my "go-to" regimens for a patient starting antiretroviral therapy (ART) without baseline resistance consist of a small handful of combinations, listed here in alphabetical order:

Of course, I have patients on many other first-line regimens. There's no reason to switch therapy in someone doing well on Atripla, Viramune, or Isentress, for example. But I generally stick with one of the choices mentioned above if I'm starting ART for the first time. Here's why:


Atripla is an effective medication that has served us well for many years, but the early and usually temporary neuropsychiatric side effects (vivid dreams, dizziness, mood and cognitive changes) have always been a drawback -- one that we don't have to put up with anymore using other combinations. It's also clear that some people have lingering side effects: depression, difficulty focusing or concentrating, or sleep changes that persist long after the more intense early side effects have resolved. These changes may be subtle, and it can sometimes be impossible to know whether they're caused by Atripla without making a switch. I leave people on Atripla if they're doing well without side effects, but I don't use it any longer in people starting ART.

Viramune becomes a fine drug after the first month or two, but it can have potentially serious and even life-threatening toxicities during the first few weeks, especially in people with high CD4 counts. Now that we're starting ART when CD4 counts are high, Viramune isn't a great choice for most people. But there's no need to switch therapy in people doing well on Viramune unless they prefer to switch to a single-tablet regimen.

Isentress is a terrific drug: it's effective, well tolerated, and has few drug interactions. Its only downsides are that it's taken twice a day (unlike Tivicay and Stribild) and isn't available in a single-tablet regimen (unlike Stribild). If you're taking other twice-daily medications anyway, there's no reason to switch, but for those who would prefer something more convenient, Stribild and Tivicay offer easier alternatives.

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