_______________________________________________________________________ HIV/AIDS: An Update
Initiation of Therapy The decision to initiate antiretroviral therapy is one that requires careful discussion with the patient, usually in con- sultation with an infectious disease specialist or other physi- cian well versed in the use of ART. Physicians and patients alike should be aware of the advantages, potential toxicities, and complexity of monitoring therapy. Clinicians should consult the appropriate HHS guideline for antiretroviral agents; separate guidelines have been developed for adults and adolescents, pediatrics, and pregnant women with HIV infection [23; 24; 42]. For adults and adolescents, a typical initial regimen consists of three HIV medications from two drug classes. At the present time, the most active triple-drug regimen in a previously untreated patient can be expected to reduce the viral load below detectable levels, increase CD4 counts by an average of 100–150 cells/mcL, reduce the risk of HIV-associated complications, and prolong survival. However, the ability to achieve this advantage depends on the patient’s willingness to accept a complex medical regimen that requires multiple medications, rigorous compliance, frequent follow-up, and moderate risk for drug toxicity. In reaching a decision it is helpful to bear in mind that prognosis is determined by viral load and the CD4 count. Patients having a viral load in excess of 100,000 copies/mL are considered to have a high HIV viral load and a relatively rapid course of disease, significantly lower- ing the average survival rate to little more than a few years. In contrast, those with a viral load <20 copies/mL have reached viral suppression and have a life expectancy similar to that of the general population. The CD4 count is also a prognostic factor, as counts less than 350 cells/mcL indicate damage to immune function and corresponding risk for opportunistic infection [19]. Antiretroviral therapy should be initiated immediately for all patients infected with HIV in order to reduce the risk of dis- ease progression and limit transmission [42]. There is growing evidence that early initiation of ART is effective in prevent- ing clinical events (e.g., non-AIDS malignancies, infection, AIDS-defining illness) regardless of pre-treatment CD4 count [42; 48; 49]. Advances in the development of antiretroviral medications, combination tablets, and injectable ART makes adherence to therapy more effective, more convenient, and better tolerated than regimens used in the past. Deferral of therapy should only be considered in patients with high CD4 counts (e.g., more than 500 cells/mcL) if adherence will be very difficult or impossible, comorbidities complicate or pro- hibit antiviral therapy, or a patient is considered a long-term non-progressor [42].
• Atripla: Efavirenz, emtricitabine, and tenofovir disoproxil fumarate • Biktarvy: Bictegravir, emtricitabine, and tenofovir alafenamide • Cimduo: Lamivudine and tenofovir disoproxil fumarate • Combivir: Lamivudine and zidovudine • Complera: Emtricitabine, rilpivirine, and tenofovir disoproxil fumarate • Delstrigo: Doravirine, lamivudine, and tenofovir disoproxil fumarate • Descovy: Emtricitabine and tenofovir alafenamide • Dovato: Dolutegravir and lamivudine • Epzicom: Abacavir and lamivudine • Evotaz: Atazanavir and cobicistat • Genvoya: Elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide • Juluca: Dolutegravir and rilpivirine • Kaletra: Lopinavir and ritonavir • Odefsey: Emtricitabine, rilpivirine, and tenofovir alafenamide • Prezcobix: Darunavir and cobicistat • Stribild: Elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate • Symfi: Efavirenz, lamivudine, and tenofovir disoproxil fumarate • Symfi Lo: Efavirenz, lamivudine, and tenofovir disoproxil fumarate • Symtuza: Darunavir, cobicistat, emtricitabine, and tenofovir alafenamide • Triumeq, Triumeq PD: Abacavir, dolutegravir, and lamivudine • Trizivir: Abacavir, lamivudine, and zidovudine • Truvada: Emtricitabine and tenofovir disoproxil fumarate • Cabenuva: Cabotegravir and rilpivirine In addition to oral medications, in 2021 the FDA approved the first monthly injectable ART—Cabenuva (cabotegravir/ rilpivirine). This monthly injectable is an optional regimen to replace a current ART regimen in patients who are virologically suppressed on a stable regimen with no history of treatment failure and with no known HIV resistance to either cabotegra- vir or rilpivirine. This regimen is intended to improve compli- ance and quality of life for patients who have achieved control of HIV on daily oral therapy. Prior to initiating injectable therapy, oral therapy with cabotegravir/rilpivirine is started to ensure the agents are well-tolerated [43; 59].
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MDCT2026
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