Dual antiretroviral therapy for HIV infection

ABSTRACT

Introduction: For two decades, triple combinations of antiretrovirals have been the standard treatment for HIV infection. The challenges of such lifelong therapy include long-term side effects, high costs and reduced drug adherence. The recent advent of more potent and safer antiretrovirals has renewed the interest for simpler HIV regimens.

Areas covered: We discuss the pros and cons of dual antiretroviral therapies in both drug-naïve and in treatment-experienced patients with viral suppression (switch strategy).

Expert opinion: Some dual antiretroviral regimens are safe and efficacious, particularly as maintenance therapy. At this time, combinations of dolutegravir plus rilpivirine represent the best dual regimen. Longer follow-up and larger study populations are needed before supporting dolutegravir plus lamivudine. In contrast, dual therapy based on maraviroc is less effective. Although dual regimens with boosted protease inhibitors plus either lamivudine or raltegravir may be effective, they are penalized by metabolic side effects and risk for drug interactions.

The newest dual regimens could save money, reduce toxicity and spare drug options for the future. For the first time in HIV therapeutics, less can be more. Dual therapy switching has set up a new paradigm in HIV treatment that uses induction-maintenance.

KEYWORDS:

• Dual antiretroviral therapy
• dolutegravir
• switch strategy
• simplification
• induction-maintenance
• drug resistance
• viral escape
• cost

Article highlights

• Some dual antiretroviral regimens may provide similar efficacy than triple recommended combinations at lower cost and improved safety as HIV maintenance antiretroviral therapy.

• Dual antiretroviral regimens based on maraviroc are suboptimal virologically.

• Dual combinations including boosted protease inhibitors may be associated to metabolic abnormalities and increased risk for drug interactions.

• The dual regimen of dolutegravir plus lamivudine needs longer follow-up and assessment of larger patient populations.

• The combination of dolutegravir plus rilpivirine is currently the preferred dual antiretroviral regimen as switching therapy.

This box summarizes key points contained in the article.

Declaration of interest

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.

Additional information

Funding

Ministerio de Economía y Competitividad (MINECO, FEDER funds, grant number MAT2015-62644.C2.2. R), from the Chair ‘Doctors Galera-Requena in cancer stem cell research’, Internal funds of Fundación MEDINA.