Beyond one pill, once daily: current challenges of antiretroviral therapy management in the United States

ABSTRACT

Introduction: Modern antiretroviral therapy (ART) has revolutionized HIV treatment. ART regimens are now highly efficacious, well-tolerated, safe, often with one multi-drug pill, once-daily regimens available. However, clinical challenges persist in managing ART in persons with HIV (PWH), such as drug–drug interactions, side effects, pregnancy, co-morbidities, and adherence.

Areas Covered: In this review, we discuss the ongoing challenges of ART for adults in the United States. We review the difficulties of initiating ART and maintaining therapy throughout adulthood and discuss new agents and strategies under investigation to address these issues. A PubMed search was utilized to identify relevant publications and guidelines through July 2019.

Expert Opinion: Challenges persist in initiation and maintenance of ART. An individual’s coexisting medical, social and personal factors must be considered in selecting and continuing ART to ensure safety, tolerability, and efficacy throughout adulthood. Continued development of new therapeutics and novel approaches to ART, such as long acting drugs or dual therapy, are needed to respond to many of these challenges. In addition, future research must address therapeutic disparities for populations historically underrepresented in clinical trials, including women, people aging with HIV, and those with complex comorbidities.

KEYWORDS:

• HIV
• Antiretroviral therapy
• women
• aging
• drug-drug interactions
• non-AIDS-related comorbidities
• Adults
• AIDS

Article highlights

• Antiretroviral therapy (ART) has transformed HIV into a chronic, manageable illness. Virally suppressive ART extends the life-expectancy of PWH to near that of the general population but requires life-long adherence.

• Selection of an initial ART regimen requires multiple considerations including baseline resistance, co-infections, and co-morbidities.

• ART remains understudied in women and during pregnancy. Women living with HIV and their providers must discuss her reproductive goals to ensure safe and effective ART.

• Multidisciplinary approaches are essential for maintaining engagement in care and viral suppression across the adult lifespan of PWH.

• Emerging ART—including dual therapy and long-acting agents—offer the promise of safer, more convenient, and more efficacious treatments.

Disclosure statement

SE Cohn has served as a scientific advisor for Merck & Co. 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

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

MCM received funding from the National Institutes of Health (T32 DK007169). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.