HIV and AIDS
Antiretroviral Options for Naïve and Virologically Controlled Patients Nadia Valin,1
Jérôme Pacanowski1 and Pierre-Marie Girard1,2
1. Department of Infectious Diseases and Tropical Medicine, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris and Faculté de Médecine Pierre et Marie Curie, Paris; 2. INSERM Unit 707, 75012 Paris
Abstract
Research on new drugs and strategies for antiretroviral therapy is continuously evolving. Recent ARVs are easier to take, mainly due to their simplification, better tolerated and at least as effective as first generation compounds on virus containment. Current guidelines are based on the results of numerous trials evaluating virological and immunological efficacy, short-term and long-term tolerability of different treatment regimens and the consequences of resistance on virological failure. All these characteristics must be taken into account when selecting a first-line regimen. The first-line treatment could nowadays be modified after a few months of virological success to a treatment with fewer drugs or side effects (induction-maintenance strategies). Here, we review the current treatment options, first for naïve, then for virologically controlled patients. We underline the various positions provided by expert groups, the gaps to bridge regarding specific research questions and the windows still open for clinical evaluation of innovative strategies.
Keywords Antiretroviral regimen, naïve patients, simplification strategies, antiretroviral related complications
Disclosure: The authors have no conflicts of interest to declare. Acknowledgement(s): The authors want to thank Jean Luc Meynard and Anders Boyd for having critically revised the manuscript. Received: 16 February 2011 Accepted: 23 August 2011 Citation: European Infectious Disease, 2011;5(2):73–9 Correspondence: Nadia Valin, Physician of Infectious Diseases, Department of Infectious Diseases, Hôpital Saint-Antoine, 184 rue du Faubourg saint Antoine, 75012 Paris, France. E:
nadia.valin@
sat.aphp.fr
Research on new drugs and strategies for antiretroviral therapy is continuously evolving. The last two decades have been particularly productive, with currently more than twenty, licensed antiretrovirals (ARV) belonging to six drug classes available in industrialised countries. Recent ARVs are easier to take, mainly due to their simplification, better tolerated and at least as effective as first generation compounds on virus containment. Therefore, an increasing number of antiretroviral combinations can be individually designed in order to control HIV replication. Not all of them have been or can be evaluated by clinical trials. In addition, given the improvement of virological efficacy and tolerance of ARVs, it has become increasingly difficult to assess the advantages of new drugs or regimens. This is particularly critical in maintenance therapy as only few trials are being performed in this setting. Hence, it is not surprising that recommendations may vary according to national or international groups, even though there is a prevailing consensus as to the aims of ARV therapy.
Here, we review the current treatment options first for naïve then for virologically controlled patients. We underline the various positions provided by expert groups, the gaps to bridge regarding specific research questions and the windows still open for clinical evaluation of innovative strategies.
Treatment Options for Naïve Patients According to all recommendations, triple ARV regimen remains the cornerstone therapy in naïve patients. The optimal time for treatment initiation in asymptomatic patients is beyond the scope of this
© TOUCH BRIEFINGS 2011
particular article. The current trend is to treat patients earlier, as illustrated by the change in international guidelines recommending the initiation of ARV therapy between 350 and 500 cells/mm3.1,2,3
The
goal is to achieve a plasma viral load less than 50 copies/ml within four to six months from starting treatment. Despite the obvious fact that tolerability should be maximised, special emphasis has recently been made on the easiness of the regimen (‘friendly regimen’) and avoiding even mild symptoms that are frequently overlooked by caregivers. Indeed, failing therapy is generally due to poor compliance. Side effects are among the determinants of suboptimal drug intake. Another reason for failing is the so-called insufficient potency of the regimen, which is often the case when plasma viral load is high (generally defined by more than 105 copies/ml). Furthermore, efficacy rankings of various regimens are often linked to subgroups of patients with higher baseline viral load. Results of numerous clinical trials are now available and make evidence-based recommendations regarding main evaluation criteria. Nevertheless, the choice of regimen must be made, while taking into account important factors, such as quality of life and other co-morbidities, particularly cardiovascular diseases.
New recommendations suggest that patients should be treated earlier during the course of HIV infection. Coupled with the growing number of patients with a hopefully earlier diagnosis, it is safe to say that the number of patients undergoing treatment will markedly increase. This has two major consequences. First, the cost of treatment will markedly increase, thereby constraining resources that pay for these expensive drugs. Until now, the cost of drugs was
73
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92