Switching strategies in the recent era of antiretroviral therapy

ABSTRACT

Introduction

Although antiretroviral therapy is highly effective, many patients may benefit from switching strategies. Rapid advances in the development of new antiretroviral drugs could enhance the success of these approaches. In this review, we build on a previous review from 2014 and summarize the current options for switching strategies in virologically suppressed HIV-infected patients.

Areas covered

We conduct a critical analysis of scientific evidence for various switching strategies used in the modern era of antiretroviral therapy, as well as reasons for these approaches, other considerations to be taken into account, and alternative strategies.

Expert opinion

Current antiretroviral regimens are effective and well tolerated in HIV patients. A number of options may provide benefit to patients, even virologically suppressed patients, possibly enhancing adherence and avoiding adverse effects and toxicities. Cost reduction may also be an important goal of switching strategies. The present scenario is excellent, as many good antiretroviral compounds and regimens allow clinicians to further improve on effective treatments now used in routine practice. Even the current paradigm of triple-drug regimens as the standard of care could change, at least in some patients.

KEYWORDS:

• Antiretroviral therapy
• HIV
• dual therapy
• simplification
• switch

Article Highlights

• The main goal of switching strategies should be to obtain benefits for virologically suppressed patients, such as improved tolerability and adherence plus continued virologic success, while also providing cost savings for the health care system.

• Although the EACS Guidelines still consider DRV monotherapy to be an alternative in certain patients, according to the U.S. Department of Health & Human Services Guidelines this strategy should not be used, as its efficacy rates are lower than those of triple-drug regimens.

• Although more data are needed, preliminary studies suggest that the availability of potent and effective new drugs may allow virologically suppressed patients with several previous VFs and certain resistant mutations to switch from complex regimens of 5 or 6 pills per day to simpler regimens with 2 pills per day.

• According to recent clinical trials, some dual-therapy regimens may be effective in switching scenarios. More data should be forthcoming.

• If phase 3 trials confirm preliminary studies, long-acting therapies, such as CAB and RPV, may be another tool to improve adherence in a number of virologically suppressed patients, allowing them to avoid the need to take pills every day of their lives.

This box summarizes key points contained in the article.

Declaration of interest

P Prieto has received honoraria for lectures from MSD. D Podzamczer has received research grants and/or honoraria for advisories and/or conferences from Viiv, Gilead, Janssen, and MSD. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript disclosed grants for educational activities for Abbvie, Gilead Sciences, Janssen-Cilag, Merck Sharp and Dohme, ViiV Healthcare, Bristol-Myers Squibb, Personal fees for advisory boards and speakers bureau for Abbvie, Gilead Sciences, Janssen-Cilag, Merck Sharp and Dohme, ViiV Healthcare and Bristol-Myers Squibb.

Additional information

Funding

This paper was not funded.