From the Guidelines
The recommended initial treatment regimen for HIV is a three-drug combination known as antiretroviral therapy (ART), typically consisting of an integrase strand transfer inhibitor (InSTI) and two nucleoside reverse transcriptase inhibitors (NRTIs), with regimens such as bictegravir or dolutegravir with 2 NRTIs being preferred options 1.
Key Considerations
- The current standard of care usually includes two NRTIs plus a third agent from another class, with InSTIs being a preferred class due to their high efficacy and favorable side effect profile.
- A commonly prescribed regimen is Biktarvy, which combines bictegravir with emtricitabine and tenofovir alafenamide in a single daily tablet.
- Alternative first-line regimens include Triumeq (dolutegravir, abacavir, and lamivudine) or Dovato (dolutegravir and lamivudine).
- Treatment should begin as soon as possible after diagnosis, regardless of CD4 count, and is lifelong.
Important Factors to Consider
- Before starting therapy, baseline laboratory tests should be performed, including HIV viral load, CD4 count, resistance testing, and screening for hepatitis B and C.
- These medications work by preventing HIV from replicating and integrating into host cells, thereby reducing viral load to undetectable levels, preserving immune function, preventing progression to AIDS, and reducing transmission risk.
- Treatment selection should consider individual factors such as potential side effects, drug interactions, comorbidities, and pregnancy status, so consultation with an HIV specialist is essential for personalized care 1.
Recent Guidelines
- The 2024 recommendations of the International Antiviral Society-USA panel suggest that antiretroviral therapy continues to be recommended for all individuals with HIV, with InSTIs being a preferred class 1.
- Long-acting injectable therapy is available for those who prefer not to take daily oral medications and for people struggling with adherence to daily therapy.
- Recommendations are provided for laboratory monitoring, management of substance use disorders and weight changes, as well as use of statins for cardiovascular disease prevention.
From the Research
Initial Treatment Regimen for HIV
The recommended initial treatment regimen for HIV typically consists of a combination of antiretroviral drugs. According to 2, the current standard of care is to start treatment as soon as feasible, using a three-drug oral daily antiretroviral regimen. This regimen usually includes two nucleoside analogue reverse transcriptase inhibitors combined with a third drug, either an integrase inhibitor, a non-nucleoside reverse transcriptase inhibitor, or a protease inhibitor.
Components of the Initial Treatment Regimen
The components of the initial treatment regimen may vary, but commonly used drugs include:
- Nucleoside reverse transcriptase inhibitors (NRTIs) such as tenofovir or zidovudine
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as efavirenz or nevirapine
- Integrase inhibitors such as dolutegravir
- Protease inhibitors such as darunavir
Efficacy and Safety of Different Regimens
Studies have compared the efficacy and safety of different regimens, including:
- Efavirenz versus nevirapine in combination with two NRTIs 3
- Dolutegravir versus darunavir in combination with tenofovir or zidovudine 4
- Dolutegravir plus lamivudine dual therapy as a new option for initial antiretroviral therapy 5
Key Findings
Key findings from these studies include:
- Efavirenz and nevirapine have equivalent efficacies in initial treatment of HIV infection when combined with two NRTIs, but different side effects 3
- Dolutegravir in combination with NRTIs is effective in treating patients with HIV-1 infection, including those with extensive NRTI resistance 4
- Dolutegravir plus lamivudine dual therapy is a viable option for initial antiretroviral therapy, with noninferior efficacy and a more favorable safety profile compared to a three-drug regimen 5