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ART Switch Barriers
Don’t Settle: Overcoming Barriers to Finding a “Perfect Fit” ART Regimen

Released: August 29, 2025

Monica Gandhi
Monica Gandhi, MD, MPH
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Key Takeaways
  • Three barriers can prevent people with viral suppression from making an evidence-based switch to an effective antiretroviral regimen that may better fit individual treatment needs:
    • Inertia or reluctance to change (by the person living with HIV or the healthcare professional)
    • Misconceptions regarding patient candidacy for a given switch strategy
    • Fear of losing viral suppression

As the HIV treatment landscape continues to evolve with ever more regimen options, people living with HIV now have many possibilities to maintain viral suppression.

However, barriers often prevent people with viral suppression from switching to an antiretroviral therapy (ART) regimen that may be a better fit when there is no urgent and obvious requirement to change treatment such as a serious adverse event or drug–drug interaction.

In this commentary, I highlight 3 case vignettes that illustrate situations where people appeared to be doing reasonably well on their current ART but experienced meaningful benefits from a proactive approach to ART switch based on a careful assessment of their treatment satisfaction. These cases also highlight key barriers that contributed to delays in the decision to switch.

Case Vignette 1: Overcoming Inertia
This case involves a person whose HIV was virally suppressed for 6 years and was receiving a first-line regimen of darunavir (DRV)/cobicistat (COBI)/emtricitabine (FTC)/tenofovir alafenamide (TAF).

During treatment, this person informed the healthcare professional (HCP) that they had been experiencing mild nausea since initiating therapy. The HCP expressed reluctance to change the regimen, emphasizing the importance of maintaining continuous viral suppression and expressing the opinion that ART switch should be avoided except in the event of a serious problem. Based on this discussion, the person decided that the nausea was tolerable and agreed to continue with the same treatment.

But after a recent move, the person began seeing a new HCP who asked about how the treatment was working. After discussing the treatment experience and exploring alternative ART regimens, the person decided to try switching to bictegravir (BIC)/FTC/TAF.

At the next clinic visit, this person reported feeling much better after the switch. The person had even resumed eating several foods previously avoided while receiving the protease inhibitor–based regimen. This person had not realized just how badly the prior regimen was upsetting their stomach until they switched, as they had simply grown used to it.

This case illustrates a sense of inertia or reluctance on the part of the HCP who thought change was warranted only if there were serious adverse events. The HCP’s inertia resulted in someone continuing an ART regimen that caused ongoing mild nausea until finally making a change.

Case Vignette 2: Candidacy
In this case a person with no history of virologic failure was receiving dolutegravir (DTG) plus FTC/tenofovir disoproxil fumarate (TDF) for 3 years following 6 years of efavirenz (EFV)/FTC/TDF.

The person expressed to the HCP that they were weary of taking 2 pills every day and that the daily act of taking pills was a constant reminder of their HIV status. They especially hated traveling internationally with HIV medication and were interested in long-acting HIV treatment options.

The HCP explained that because drug resistance testing was not performed when the person was initially diagnosed with HIV, they felt that it would not be safe to switch to long-acting (LA) cabotegravir (CAB) plus rilpivirine (RPV) without performing proviral DNA sequencing. Unfortunately the clinic did not have access to that testing.

The person continued receiving DTG plus FTC/TDF for another year before traveling to a larger clinic approximately an hour away to try to obtain proviral DNA sequencing. The HCP at the larger clinic explained that proviral DNA sequencing is not required for a switch to LA CAB plus RPV, and the person felt comfortable making the change with careful HIV-1 RNA monitoring for a few months afterward.

Following this switch, the person maintained viral suppression and was able to continue receiving LA ART from the local clinic. At a follow-up visit, they shared that not having a daily reminder of HIV and being able to travel without HIV medication was extremely liberating. The person stated that for the first time in 10 years, they were actually able to forget about the HIV for days at a time.

In this case, the treatment team had misconceptions about patient candidacy for a switch, delaying a reasonable evidence-based switch to LA therapy that was liberating for the person and reduced feelings of internalized stigma.

Case Vignette 3: Fear of Losing Viral Suppression
This final case features a person who received RPV/FTC/TDF for 1 year, with continuous viral suppression. They were hepatitis B virus immune through childhood vaccination, and baseline resistance testing at diagnosis showed no resistance associated mutations.

This person had recently spoken with a friend who had started a 2-drug HIV regimen. After this conversation, they were having a hard time adjusting to the idea that they were taking 3 different medicines even though it was only 1 pill. They never had to take regular medication before and had always preferred to use natural or herbal remedies.

But when the individual asked the HCP about ART regimens that contain 2 instead of 3 drugs, the HCP explained that 2-drug regimens could put the person at higher risk for virologic failure and potentially develop drug resistance. The HCP left it up to the person to decide but stressed that they would feel much more comfortable if the person continued the 3-drug regimen.

Essentially the HCP feared loss of virologic efficacy with a switch from a 3-drug to a 2-drug oral regimen, despite evidence demonstrating high rates of maintained viral suppression with the switch in question.

The person decided that the peace of mind from being on fewer drugs was worth the HCP’s assessment of risk and resolved to switch back to a 3-drug regimen if the 2-drug option did not work. The HCP reluctantly switched the regimen to DTG/RPV, and the person continued to maintain viral suppression.

By the next clinic visit, the individual felt much more confident about being on 2 drugs instead of 3, and the 2-drug regimen made them feel less reluctant to take the medication each day.

Overcoming Barriers
These cases highlight 3 key barriers to ART switches even when they are supported by evidence-based rationale and could provide considerable benefits.

To address these barriers, it is critical that HCPs recognize that there are now almost always multiple options for effective virologically suppressive ART, creating space to prioritize patient insights and preferences.

Making sure that each person living with HIV is receiving the “perfect fit” ART regimen requires having regular conversations to assess for challenges that they may be experiencing with a given treatment and then engaging in shared decision-making about potential switch strategies based on the available data and expert guideline recommendations.

Your Thoughts
Have you experienced any of these barriers when it comes to making sure each person living with HIV in your care is receiving an ART regimen that is both highly effective and fits well with their lifestyle and personal preferences? Have you encountered other barriers? Share your thoughts by posting a comment.

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