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Older Woman With CV Risk, Reduced Renal Function
Optimal First-line ART for an Older Woman With Cardiovascular Risk Factors and Minor Diminution of Renal Function

Released: April 10, 2017

Expiration: April 09, 2018

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In this HIV cases series, we highlight common patient case scenarios and the critical decision making that goes into selecting optimal patient management strategies. This case features an HIV-infected woman in her mid-50s. Herein, I discuss key considerations for what may influence a clinician’s choice of DHHS-recommended first-line ART in this older woman with cardiovascular risk factors and moderately diminished renal function.

Case Details
A 54-year-old postmenopausal woman presents with new-onset Bell’s palsy. She is divorced but reports a new male partner with whom she has not been practicing safe sex. She smokes tobacco (up to 1 pack/day for multiple years) and reports a family history of coronary artery disease.

Because syphilis is among the causes of Bell’s palsy, the patient is assessed for this sexually transmitted infection and for HIV. Both tests return positive. Her CD4+ cell count is 420 cells/mm3 with an HIV-1 RNA of 160,000 copies/mL and a wild-type HLA-B*5701 genotype. Other lab results include hemoglobin of 10.4 g/dL, serum creatinine of 1.4 mg/dL, and an estimated glomerular filtration rate (eGFR) of 59 mL/min/1.73 m2.

Key Considerations
Current DHHS guidelines for first-line ART recommend that all individuals infected with HIV should initiate treatment regardless of CD4+ cell count. The characteristics, then, that factor into choosing an optimal regimen for this patient include her age, sex, cardiovascular risk factors, and renal function.  Recommended regimens for initial ART in the DHHS guidelines are as follows:


  • Dolutegravir (DTG)/abacavir (ABC)/lamivudine (3TC)
  • DTG + emtricitabine (FTC)/tenofovir alafenamide (TAF)
  • DTG + FTC/tenofovir disoproxil fumarate (TDF)
  • Elvitegravir (EVG)/cobicistat (COBI)/FTC/TAF
  • EVG/COBI/FTC/TDF
  • Raltegravir (RAL) + FTC/TAF
  • RAL + FTC/TDF
  • Darunavir (DRV) + ritonavir (RTV) + FTC/TAF
  • DRV + RTV + FTC/TDF

Less Optimal Regimens and Those to Avoid
Even though the patient is HLA-B*5701 negative, an ABC-containing regimen such as DTG/ABC/3TC may not be ideal because of the potential increased risk of cardiac events reported in some studies and given her baseline increased risk of cardiovascular disease. Recent data from the D:A:D cohort have also suggested the potential for increased risk of cardiovascular disease events with cumulative use of RTV-boosted DRV, making this a potentially less favorable option for the case patient.

The coformulation of EVG/COBI/FTC/TDF is not recommended in this patient because of an eGFR < 70 mL/min/1.73 m2 (Table). In fact, any TDF-containing regimen should be avoided, as this agent worsens the risk of osteoporosis or osteopenia, which increases in women as they age, especially post menopause. This further eliminates DTG or RAL when combined with FTC/TDF.

Table. Renal Considerations for Recommended Initial Regimens


Preferred Treatment Options
TAF-based regimens would be optimal for this patient. The most appropriate once-daily options include DTG + FTC/TAF (2 pills) and EVG/COBI/FTC/TAF (1 pill). If twice-daily dosing is acceptable, RAL + FTC/TAF (3 pills) is another viable option. In total, these options avoid potential exacerbation of the patient’s comorbidities with ABC, TDF, or DRV/RTV and would treat her HIV infection well.

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When selecting an initial ART regimen for an older women with moderate renal impairment and elevated cardiovascular disease risk in your clinical practice, which of the following is your preferred choice?
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