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Uncomplicated Case
My Approach to Selecting First-line ART for a Patient With Many Options

Released: July 10, 2015

Expiration: July 08, 2016

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I recently met a new patient who was referred to my practice to initiate ART for newly diagnosed HIV infection. He is 27 years of age and his HIV-1 RNA was 76,000 copies/mL with a CD4+ cell count of 405 cells/mm3. He has no comorbidities, no allergies, and is receiving no other medications. In short, he is what you might call an “uncomplicated” case. In such a case, how should we decide which regimen to start?

Breaking Down the Options
In 2015, we have several highly effective regimens available that most patients tolerate extremely well. In my practice, I begin the process of identifying an initial ART regimen by engaging the patient in a conversation about which options are available and how each regimen must be taken, including dosing, number of tablets, and food requirements. In addition, I ask about the patient’s lifestyle and attempt to identify any adherence concerns. For a patient such as this, who is a good candidate for several highly effective regimens, many clinicians may recommend the regimens they are most familiar with and most accustomed to prescribing. Based on recent updates to ART guidelines in high-income countries, most of us in these settings may find that integrase inhibitor (INSTI)–based regimens are the most commonly used initial regimens. Clearly, INSTI-based regimens offer an excellent combination of efficacy and tolerability, as well as simplicity of dosing in 2 fixed-dose combinations (elvitegravir EVG/cobicistat COBI/tenofovir TDF/emtricitabine FTC and dolutegravir DTG/abacavir ABC/lamivudine 3TC). Meanwhile, the boosted PI–based regimen of darunavir (DRV)/ritonavir (RTV) + TDF/FTC is an attractive option for ART-naive patients who may have adherence concerns. However, efavirenz (EFV)/TDF/FTC, now listed as an alternative regimen in the DHHS guidelines, remains an excellent choice for many patients and indeed is still widely used worldwide, including in nations where the availability and/or cost of INSTI-based regimens may be limiting. Moreover, along with several other options, EFV/TDF/FTC is still considered a recommended first-line regimen in the IAS-USA and WHO ART guidelines.

My Approach
After speaking with the patient I described, I learned that he had a strong preference for receiving a fixed-dose combination, and with that information, I was able to make a treatment recommendation. If you want to learn more about how my colleagues and I arrive at treatment decisions for uncomplicated patients such as this, as well as a host of other patient scenarios, I invite you to attend an upcoming satellite symposium at the International AIDS Society meeting entitled, “What I Use and Why: Expert Strategies for Selecting the Best ART Regimen for Each Patient.” On Saturday, July 19, in Vancouver, I will gather with my colleagues, Joseph J. Eron, Jr., MD; Anton L. Pozniak, MD, FRCP; and Mark A. Wainberg, PhD, in an interactive, case-based session about selecting ART.

Your Thoughts?
How do you approach first-line therapy in an “uncomplicated” case and what regimen would you prescribe for the patient I described? I invite readers to post their thoughts in the comments section below.

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Do you currently have a “go-to” first-line regimen for patients who are eligible for several regimens?
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