Which First-Line HIV Treatment Regimen Is Least Toxic? An HIV Doc Responds

Executive Editor
Joel Gallant, M.D., M.P.H.
Joel Gallant, M.D., M.P.H.

The good news about starting HIV treatment these days is that, in areas with easy access to medications, people have a wealth of regimens to choose from that work well and are unlikely to cause serious side effects. In fact, the many options can make choosing between potential regimens feel like an exhausting, confusing exercise.

Fortunately, some of the world's foremost clinical experts on HIV are online and eager to help. On his personal Tumblr, Joel Gallant, M.D., M.P.H., a renowned HIV physician at Southwest CARE Center in Santa Fe, New Mexico, answers questions from people living with HIV on a number of issues, including concerns about first-line treatment options.

On June 5, an anonymous user asked:

I'm going to start my HIV medication soon, and my doctor told me that I can take Atripla (efavirenz/tenofovir/FTC), Complera (rilpivirine/tenofovir/FTC), Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide), Odefsey (emtricitabine/rilpivirine/tenofovir alafenamide) or Stribild (elvitegravir/cobicistat/FTC/tenofovir). Can you tell me, please, which one of these medications is least toxic?

Gallant answered:

I hope your doctor didn't just give you a list of five regimens to choose from without helping you decide. You'd get better advice from a high-school graduate at Best Buy when you try to pick a TV!

  • Atripla: No. It's no longer recommended because of its toxicity.
  • Complera: No. Why take Complera when you could take the new, improved version, Odefsey?
  • Stribild: No. Why take Stribild when you could take the new, improved version, Genvoya?
  • Genvoya: A good choice, as long as you're not taking medications that interact, including certain inhaled or nasal steroid sprays for asthma or allergies, among others.
  • Odefsey: A good choice if 1) your viral load is below 100,000, 2) your CD4 count is above 200, 3) you don't take medications for heartburn or ulcers, 4) you will be able to take your medications daily with a full meal and 5) you don't intend to miss doses.

He didn't mention two other excellent, recommended regimens, which in my mind are preferred in people who may sometimes miss doses.

  • Triumeq (abacavir/dolutegravir/lamivudine): A good single-table regimen for people with a negative HLA-B*5701 test who don't have multiple risk factors for heart disease.
  • Descovy (emtricitabine/tenofovir alafenamide) + Tivicay (dolutegravir): Two pills a day, but unlike Genvoya there are few drug interactions, and unlike Triumeq you don't have to worry about HLA-B*5701 testing or heart issues. This tends to by my choice in people who don't mind taking two pills a day.

It's important to remember that, although Gallant is one of the world's most respected HIV clinicians, these recommendations are his personal opinions. As he himself suggested in the above response, it's important that people's own doctors help them to decide which treatment option is best to start with. There are also plenty of additional issues to consider when starting HIV medications; potential side effects are just one of them.

The question and answer have been lightly edited for clarity and grammar.

Joel Gallant, M.D., M.P.H., is the associate medical director of specialty services at Southwest CARE Center in New Mexico. You can ask him a question directly on his Tumblr page, Ask Dr. Joel.

Myles Helfand is the editorial director of TheBody.com and TheBodyPRO.com. Follow Myles on Twitter: @MylesatTheBody.