Program Overview
The Department of Health and Human Services regularly updates its recommendation for initiating combination antiretroviral (ARV) therapy in HIV-positive patients. Combination ARV therapy can achieve sustained suppression of viral replication and reduce morbidity and mortality rates in patients with advanced HIV infection. However, the guidelines for when to initiate therapy, and with which agents, in asymptomatic patients are less clear. Ideally, the initial treatment regimen should induce full virologic suppression, have limited side effects, and preserve future treatment options. The recommended initial regimens include 2 nucleoside reverse transcriptase inhibitors plus either a non-nucleoside reverse transcriptase inhibitor or a ritonavir-boosted protease inhibitor. However, the decision regarding which treatment to use is a difficult one, because each regimen has its own safety and tolerability challenges. For example, some agents induce dyslipidemia and other metabolic complications, which may adversely affect a patient’s cardiovascular risk profile. Physicians need to be aware of the relative propensity of ARV therapy to induce metabolic changes, and must also be able to manage these complications once they occur. In addition to safety, the dosing regimen should also be considered, as difficult regimens and food restrictions can adversely impact a patient's adherence. Coformulations have been introduced that simplify dosing regimens for patients. HIV treatment strategies also have different effects on viral resistance; for example, regimens with low genetic barriers to resistance may lead to a higher risk of resistance if virologic breakthrough occurs. Importantly, even treatment-naive patients may harbor drug-resistant virus; therefore, all patients should undergo resistance testing before initiating therapy. This educational activity has been designed to address the considerations involved in choosing an initial regimen for starting a patient on ARV therapy, preventing and managing metabolic changes, increasing adherence, and preventing viral resistance.
