Switching Strategies

With currently available antiretroviral therapy (ART), most people living with HIV (PLHIV) can achieve and maintain HIV viral suppression.1 However, just because viral suppression is achieved, it should not be assumed that the HIV-positive person is well adapted and tolerating the current regimen.2 Issues of tolerability, dosing frequency, pill count and age-related comorbidities may necessitate the introduction of an alternative treatment strategy.

Switch strategies for HIV in the setting of viral suppression

Indications for switching ART regimens in the setting of viral suppression include:2

  • Documented toxicity caused by one or more of the antiretrovirals included in the regimen (e.g. lipoatrophy, central nervous system adverse events, diarrhoea and jaundice, proximal renal tubulopathy and low bone mineral density).
  • Prevention of long-term toxicity (e.g. lipoatrophy and proximal renal tubulopathy).
  • Avoid serious drug-drug interactions.
  • Planned pregnancy.
  • Ageing and/or comorbidity with a possible negative impact of drug(s) in current regimen (e.g. cardiovascular risk, metabolic parameters).
  • Simplification: to reduce pill burden, adjust food restrictions and improve adherence.
  • Starting of HCV treatment in case of drug-drug interaction.

Principles of switching ART in the setting of viral suppression

The primary goal for regimen switching is to maintain viral suppression while eliminating or improving adverse events, facilitating adequate treatment of comorbid conditions, and improving life long, good health outcomes.1, 2

The European AIDS Clinical Society (EACS) has issued several principles for health care professionals (HCPs) to consider prior to switching ART regimens.

These include:2

A complete ART history with viral load, tolerability issues and cumulative genotypic resistance history should be analysed prior to any drug switch.

Regimens including boosted protease inhibitors (PI) may be switched to a specific unboosted PI, a non-nucleoside reverse transcriptase inhibitor, or an integrase strand transfer inhibitor only if full activity of the two nucleos(t)ide reverse transcriptase inhibitors remaining in the regimen can be guaranteed.

Before switching, consider remaining treatment options in case of potential virological failure of the new regimen.

Switches of single drugs with the same genetic barrier is usually virologically safe in the absence of resistance to the new compound.

HCPs should carefully review the possibility of drug-drug interactions with the new regimen.

Clinicians should check the HBV status and ensure regimen remains active against HBV if chronic HBV infection is present.

HIV-positive persons should be seen soon (e.g. 4 weeks) after treatment switches to check for maintenance of suppression and possible toxicity of the new regimen.

If a HIV-positive person receives and tolerates a regimen that is no longer a preferred option, there is no need to change unless there is an indication for switching, for example, to avoid long term toxicity.

Treatment guidelines

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Regimen Selection

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