US updates HIV treatment guidelines

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The US Department of Health and Human Services (HHS) has released updated HIV treatment guidelines that remove Atripla (efavirenz/tenofovir/emtricitabine) from the priority list of first-line antiretrovirals. Both Atripla and Norvir (ritonavir)–boosted Reyataz (atazanavir) plus Truvada (tenofovir/emtricitabine) have been downgraded from “recommended” regimens for treatment-naive people with HIV to an “alternative” category.

Atripla, which was the first single-pill HIV regimen approved by the US Food and Drug Administration (FDA), lost its place as a prioritized treatment based on concerns about its Sustiva (efavirenz) component, in particular the high rate of central nervous system-related side effects and a possible link to suicidality.

Norvir–boosted Reyataz plus Truvada was downgraded because of a large clinical trial that showed people taking the regimen had a higher rate of discontinuation because of side effects when compared with those taking Truvada plus either Isentress (raltegravir) or Norvir–boosted Prezista (darunavir).

HHS recommends five regimens for first-line treatment: four based on integrase strand transfer inhibitors (ISTIs) and one based on a boosted protease inhibitor (PI).

The ISTI regimens include: Triumeq (dolutegravir/abacavir/lamivudine), but only for those who have tested negative for the HLA-B*5701 genotype, meaning they are unlikely to have a dangerous “hypersensitivity” reaction to the Ziagen (abacavir) component; Tivicay (dolutegravir) plus Truvada; Stribild (elvitegravir/cobicistat/tenofovir/emtricitabine), but only for those who, before starting HIV treatment, have a creatinine clearance rate greater than 70 milliliters per minute, indicating higher kidney function; and Isentress (raltegravir) plus Truvada.

The boosted PI regimen is Norvir–boosted Prezista plus Truvada.

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