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HIV Treatment Guidelines

August 2013

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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 HIV drug should be used by itself. There are many drugs to choose from. The 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)

Your first treatment regimen will probably contain:

  • An NNRTI plus 2 NRTIs or
  • 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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The guidelines rank specific drug combinations as preferred, alternative, acceptable, and acceptable with caution (see below). While the preferred 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 HIV Drugs and the HIV Lifecycle info sheet. For more information on individual drugs sorted by class see The Well Project's 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 paraetheses. For example: Truvada (emtricitabine + tenofovir).

Preferred 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. Preferred regimens included:

  • Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen

    • Atripla (efavirenz + tenofovir + emtricitabine)
  • Protease Inhibitor (PI)-based regimens

    • Prezista (darunavir) once daily and low-dose Norvir and Truvada (tenofovir + emtricitabine)
    • Reyataz (atazanavir) and low-dose Norvir and Truvada
  • Integrase inhibitor-based regimen

    • Isentress (raltegravir) and Truvada
  • Preferred regimen for pregnant women

    • Kaletra (lopinavir/ritonavir) twice-daily
    • Reyataz (atazanavir) and low-dose Norvir and Combivir (zidovudine + lamivudine)

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 + emtricitabine) or (2) Sustiva (efavirenz ) + Viread (tenofovir) + Epivir (lamivudine). These two regimens are also those recommended for women who are pregnant or breastfeeding.

Alternative Regimens

These combinations have been proven useful in clinical trials, but may have disadvantages, such as less effectiveness or more side effects. Alternative regimens include:

  • NNRTI-based regimens

    • Sustiva (efavirenz) and Epzicom (abacavir + lamivudine)
    • Complera (emtricitabine + rilpivirine + tenofovir)
    • Edurant (rilpivarine) and Epzicom
  • PI-based regimens

    • Kaletra and low-dose Norvir once or twice daily and Epzicom or Truvada
    • Lexiva (fosamprenavir) and low-dose Norvir (once or twice daily) and Epzicom or Truvada
    • Reyataz and low-dose Norvir and Epzicom
    • Prezista and low-dose Norvir and Epzicom
  • Integrase inhibitor-based regimen

    • Stribild (Elvitegravir + cobicistat + tenofovir + emtricitabine)
    • Isentress and Epzicom

Acceptable Regimens

These combinations can be used in certain circumstances, but are not as good as preferred or alternative regimens. Acceptable regimens include:

  • NNRTI-based regimens

    • Efavirenz and Combivir
    • Viramune and Truvada or Combivir or Epzicom
    • Edurant and Combivir
  • PI-based regimens

    • Reyataz (without Norvir) and Epzicom or Combivir
    • Reyataz with low-dose Norvir and Combivir
    • Prezista (darunavir) and low-dose Norvir and Combivir
    • Lexiva and low-dose Norvir and Combivir
    • Kaletra and low-dose Norvir and Combivir
  • Integrase inhibitor-based regimen

    • Isentress and Combivir
  • Entry inhibitor-based regimens

    • Selzentry (maraviroc) and Combivir
    • Selzentry and Truvada or Epzicom

Acceptable With Caution Regimens

These combinations have been shown to be effective, but may have some safety or resistance concerns. Regimens that may acceptable when used with caution include:

  • PI-based regimens

    • Invirase (saquinavir) and low-dose Norvir and Truvada or Epzicom or Combivir
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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.
 
See Also
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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