Treatment strategies for HIV

Prior to 2016, the initiation of antiretroviral therapy (ART) was typically deferred until an individual’s CD4+ count fell below a threshold of approximately 350 cells/mm3 or they developed a HIV-associated illness.1 However, international guidelines now recommend starting ART in all HIV infected persons, regardless of CD4+ cell count, to reduce the risk of disease progression and to prevent transmission.2-5

The Strategic Timing of Antiretroviral Therapy (START) trial demonstrated that commencement of ART in asymptomatic, HIV-positive individuals with higher CD4+ counts (>500 cells/mm3) was more beneficial than initiating therapy after CD4+ T-cell counts had declined to 350 cells/mm3. The START study provided support for widespread use of ART in all people living with HIV (PLHIV) as a means of reducing the future spread of HIV.1

Initiating ART

For PLHIV who are naïve to ART, the European AIDS Clinical Society (EACS) recommends initial treatment with dual NRTI therapy, combined with either:2

  • An integrase strand transfer inhibitor (INSTI)*.
  • A non-nucleoside reverse transcriptase inhibitor (NNRTI)*.
  • A protease inhibitor (PI)* pharmacologically boosted with a CYP3A inhibitor or ‘boosting agent’.

However, an individual’s readiness to start ART, their likelihood of remaining adherent, adverse effect profiles, drug interaction potential, hepatic and renal function, presence of viral hepatitis coinfection or other comorbidities must also be considered when selecting the optimal regimen.2

*Not all INSTIs, NNRTIs or PIs are recommended as part of first-line regimens for HIV-positive persons

 

Factors to consider when initiating or switching ART

Although the EACS Guidelines recommend initiation of ART as soon as possible, various individual- and treatment-related factors need to be taken into consideration.2,3

Individual considerations include the following:2,3

  • Lifestyle
  • Baseline viral load and CD4 count
  • Prior side effects
  • Comorbidities and coinfections
  • Concomitant medications
  • Adherence potential, both today and over the course of a lifetime
  • Baseline resistance
  • Planned pregnancy

Treatment considerations include:2,4

  • Virological efficacy
  • Potential short- or long-term side effects
  • Pill burden
  • Dosing frequency
  • Drug–drug interaction potential
  • Cost
  • Potential toxicity
  • Convenience
  • Food effects

Improving adherence:

Evidence suggests that adherence to ART can be improved with the following initiatives:3,4

 

  • Peer counsellors
  • Mobile phone text messages
  • Reminder devices
  • Cognitive-behavioural therapy
  • Behavioural skills training and medication adherence training
  • Fixed-dose combinations and once-daily regimens
  • Resources to assist with treatment costs to maintain uninterrupted access to both ART and appointments
  • Allowing flexible appointment scheduling
  • Assisting with transportation

The most appropriate ART regimen is one based upon assessment of the ease of adherence, tolerability and efficacy, according to current guidelines, while accounting for the individual’s wishes, context, lifestyle, comorbidities and other medications.

Treatment guidelines

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Regimen Selection

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