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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 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.1–3
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.1–3
Tenofovir/emtricitabine/rilpivirine should not be prescribed as initial treatment for these patients but is a recommended alternative regimen.1–3 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 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).1–3
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Competing interests: None declared.
This article has been peer reviewed.