In Their Own Words: First-Line Regimens

Among several first-line antiretroviral regimens for treatment-naive people recommended by the U.S. Department of Health and Human Services (DHHS)*, the following two are designated as "preferred":

Other first-line regimens are considered "alternative," although the guidelines state that "based on individual patient characteristics, a regimen listed as alternative ... may actually be the preferred regimen for a selected patient."

With these recommendations in mind, BETA asked board members of the American Academy of HIV Medicine (AAHIVM)** the following question:

"What first-line regimen do you recommend for different populations, and why?"

Jonathan Appelbaum, MD

Fenway Community Health, Boston

Generally, I use efavirenz with Truvada [FTC/tenofovir] as my first-line therapy for most patients. For women who are pregnant or planning to become pregnant, I still use nelfinavir [Viracept] and Combivir [AZT/3TC]. For populations with low CD4 cell counts (below 100 cells/mm³) and/or viral loads over 100,000 copies/mL, I tend to start with a boosted protease inhibitor such as Kaletra or boosted atazanavir [Reyataz] with Combivir or Truvada. For African Americans I try to use efavirenz, but if there are problems with tolerance I will switch to either nevirapine [Viramune] or to boosted atazanavir.

Judith Feinberg, MD

University of Cincinnati College of Medicine

The way I conceptualize and deal with first regimens is absolutely individualized to a given patient and his or her situation.

Marah J. Lee, DO, FACP

Private practice, Ft. Lauderdale

I recommend either Combivir with fosamprenavir [Lexiva] twice daily, or Epzicom [3TC/abacavir] with Lexiva, depending on the patient's daily habits. With these combinations, I see a rapid decline in viral load and good tolerability.

Michelle Roland, MD

University of California, San Francisco

I don't have a single first-line regimen for any population. I make recommendations based upon a series of questions about the patient's life patterns (such as sleeping and eating) and preferences (pill number, size, type, and texture; concerns about PI side effects; concerns about NNRTI resistance) and their assessment of their adherence likelihood.

John Stansell, MD

Positive Health Program, San Francisco General Hospital

This is a complex question. All therapy needs to be based on viral susceptibility and the patient's drug tolerance, but for the naive patient with adequate immune reserve (i.e., over 100 CD4 cells/mm³), I would generally start with a once-daily regimen. First-line is probably tenofovir/3TC/efavirenz. If the patient is reluctant to take efavirenz, I will use tenofovir/3TC/boosted atazanavir. If they don't want to use a PI, I try twice-daily nevirapine. For the person presenting with advanced disease, say after an OI, I use a Kaletra-based regimen.

These are gross generalities. The nuance of antiretroviral use is the art of HIV management.

Aimee Wilkin, MD, MPH

Wake Forest University School of Medicine, Winston-Salem

In general, I tailor first-line regimens based on a discussion with the patient regarding lifestyle, feelings about a once-a-day regimen, predictable side effects, and other medical problems such as kidney disease, liver disease, and depression. A typical choice would be two NRTIs in a combination pill plus an NNRTI (usually Truvada/efavirenz or Combivir/efavirenz). For patients who might not do well with an NNRTI, I'd use a boosted PI regimen with two NRTIs. There are at least three choices for a good boosted PI regimen, and the choice varies depending on the predicted side effect profile, drug interactions, and other medical problems that the patient has.

* Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents from the DHHS was last updated October 29, 2004. The complete document is available online at www.aidsinfo.nih.gov/guidelines.

** The American Academy of HIV Medicine is an independent organization of AAHIVM-certified HIV Specialists and others dedicated to promoting excellence in HIV/AIDS care. The Academy's definition of the HIV Specialist incorporates both Continuing Medical Education (CME) units and clinical experience, and requires that frontline providers who wish to be considered HIV Specialists meet these qualifications on a recurrent basis. For more information, see www.aahivm.org.

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