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CMAJ. 2016 September 20; 188(13): 971.
PMCID: PMC5026515

Single-tablet antiretroviral treatment (once daily)

Single-tablet antiretroviral treatment taken once daily improves adherence and quality of life compared with multiple-pill regimens

Current guidelines recommend combination antiretroviral treatment for all patients with HIV infection.1,2 The backbone of this treatment regimen is a dual nucleoside reverse transcriptase inhibitor combination, typically tenofovir/emtricitabine or abacavir/lamivudine, which is combined with a non-nucleoside reverse transcriptase inhibitor, integrase strand-transfer inhibitor or boosted protease inhibitor.3 A meta-analysis of randomized controlled trials (RCTs) showed higher pill burden is inversely associated with adherence to combination antiretroviral treatment and virologic suppression, which provides a rationale for using single-tablet regimens.4

Abacavir/lamivudine/dolutegravir has the highest genetic barrier to resistance; however, there is a risk of hypersensitivity

Abacavir/lamivudine/dolutegravir is recommended as first-line treatment based on RCT evidence.1,2 Abacavir is associated with severe hypersensitivity reactions in patients with the HLA-B5701 allele.1,3 Pretreatment genetic testing is indicated, and abacavir should be avoided if test results are positive for the presence of the allele.2,3 Dolutegravir is an integrase strand-transfer inhibitor with minimal adverse effects and a high genetic barrier to resistance.13

Tenofovir/emtricitabine/efavirenz is associated with neuropsychiatric adverse effects

Tenofovir/emtricitabine forms the backbone in three of four single-tablet regimens and is the preferred treatment for HIV/hepatitis B virus co-infection.1 Tenofovir/emtricitabine/efavirenz is recommended only as an alternative regimen, because efavirenz is associated with neuropsychiatric symptoms and may increase suicidality.1,2 Tenofovir may cause renal toxicity and osteoporosis.13

Tenofovir/emtricitabine/rilpivirine is less effective in patients with pretreatment HIV viral loads greater than 100 000 copies/mL or CD4 counts less than 200 cells/μL

Tenofovir/emtricitabine/rilpivirine should not be prescribed as initial treatment for these patients but is a recommended alternative regimen.13 Rilpivirine is a non-nucleoside reverse transcriptase inhibitor with less central nervous system toxicity than efavirenz.1 Adequate absorption requires administration in conjunction with a high-energy meal (> 400 kcal).1 Rilpivirine should not be prescribed to patients taking proton pump inhibitors and should be prescribed with caution in patients taking other acid-lowering drugs.1,3

Tenofovir/emtricitabine/elvitegravir/cobicistat is well-tolerated but associated with multiple drug interactions

Tenofovir/emtricitabine/elvitegravir/cobicistat is recommended first-line therapy based on RCT evidence.1 It is contraindicated if creatinine clearance is less than 70 mL/min.1,3 Elvitegravir, which is an integrase strand-transfer inhibitor, has a lower genetic barrier to resistance than dolutegravir.1,2 Cobicistat is a cytochrome P450 3A4 inhibitor that acts to increase elvitegravir levels in plasma.2 However, it has the potential for multiple drug interactions (e.g., with statins and rifampin).13

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Footnotes

Competing interests: None declared.

This article has been peer reviewed.

References

1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Bethesda (MD): Department of Health and Human Services; 2014. Available: www.aidsinfo.nih.gov/contentfiles/adultandadolescentgl.pdf (accessed 2015 Oct. 16).
2. Günthard HF, Aberg JA, Eron JJ, et al. Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society — USA Panel. JAMA 2014;312:410–25. [PubMed]
3. Gandhi M, Gandhi RT. Single-pill combination regimens for treatment of HIV-1 infection. N Engl J Med 2014;371:248–59. [PubMed]
4. Nachega JB, Parienti J, Uthman OA, et al. Lower pill burden and once-daily antiretroviral treatment regimens for HIV infection: a meta-analysis of randomized controlled trials. Clin Infect Dis 2014; 58:1297–307. [PMC free article] [PubMed]

Articles from CMAJ : Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association