Choice of initial therapy.

Area of Science:

• Infectious Diseases
• Virology
• Pharmacology

Background:

• International and national guidelines (EACS, BHIVA, DHHS, IAS) regularly update recommendations for initial combination antiretroviral treatment (cART) regimens.
• Preferred cART regimens typically involve a backbone of two nucleoside/nucleotide reverse transcriptase inhibitors combined with non-nucleoside reverse transcriptase inhibitors, ritonavir-boosted protease inhibitors, or integrase inhibitors.
• Recent improvements in tolerability have led to increased response rates based on viral load measurements.

Purpose of the Study:

• To discuss the selection of initial cART regimens based on current international guidelines.
• To explore the evidence supporting the individualization of initial HIV therapy.
• To highlight the factors influencing the choice of initial HIV treatment.

Main Methods:

• Review of current international and national treatment guidelines for HIV.
• Analysis of factors influencing the choice of initial cART, including viral load, resistance testing, CD4 count, comorbidities, drug interactions, adverse events, pregnancy potential, convenience, adherence, cost, and patient/physician preferences.
• Discussion of evidence for different cART components (boosted protease inhibitors, non-nucleoside reverse transcriptase inhibitors, integrase inhibitors).

Main Results:

• A variety of potent initial cART regimens are available.
• The selection of an initial regimen is a flexible process influenced by multiple clinical and personal factors.
• Evidence-informed data and individualized concepts, some with limited strong evidence, guide regimen choice.

Conclusions:

• The choice of initial HIV therapy requires a combination of evidence-based recommendations and personalized patient considerations.
• Individualized approaches, while partly supported by evidence, play a significant role in optimizing initial cART selection.
• Understanding the nuances between different drug classes is crucial for effective initial HIV treatment decisions.