This document discusses guidelines for initial antiretroviral therapy and recent clinical trials comparing different first-line regimens. The 2013 DHHS and 2012 IAS-USA guidelines recommend efavirenz (EFV) plus tenofovir/emtricitabine (TDF/FTC) or abacavir/lamivudine (ABC/3TC) as preferred initial regimens. Recent trials found rilpivirine (RPV) to be noninferior to EFV through week 96, though with more virologic failures, especially in those with high baseline viral load. Elvitegravir/cobicistat/TDF/FTC was noninfer

1. First and Foremost:
Choosing and Using First-line
Antiretroviral Therapy
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2. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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3. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Program Director
Daniel R. Kuritzkes, MD
Chief, Division of Infectious Diseases
Brigham and Women’s Hospital
Professor of Medicine
Harvard Medical School
Boston, Massachusetts

4. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Faculty
Judith S. Currier, MD, MSc
Paul E. Sax, MD
Eric S. Daar, MD
Kimberly Y. Smith, MD, MPH
Professor of Medicine
Chief, Division of Infectious
Diseases
David Geffen School of Medicine
University of California, Los
Angeles
Los Angeles, California
Chief, Division of HIV Medicine
Harbor-UCLA Medical Center
Professor of Medicine
David Geffen School of Medicine
at UCLA
Los Angeles, California
Clinical Director
HIV Program and Division of
Infectious Diseases
Brigham and Women’s Hospital
Professor of Medicine
Harvard Medical School
Boston, Massachusetts
Associate Professor of Medicine
Division of Infectious Diseases
Rush University Medical Center
Chicago, Illinois

5. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Disclosures
Daniel R. Kuritzkes, MD, has disclosed that he has received consulting fees
from Bristol-Myers Squibb, Celera, Gilead Sciences, GlaxoSmithKline,
InnoVirVax, Merck, and Tobira; fees for non-CME services from Gilead Sciences
and ViiV; and funds for research support from Gilead Sciences and Merck.
Judith S. Currier, MD, MSc, has disclosed that she has received consulting fees
from Serono and ViiV and has received funds for research support from Merck.
Eric S. Daar, MD, has disclosed that he has received consulting fees from
Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck, and ViiV and funds for
research support from Bristol-Myers Squibb, Gilead Sciences, Merck, and ViiV.
Paul E. Sax, MD, has disclosed that he has received consulting fees from BristolMyers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen, and Merck. Grants to
Harvard Medical School have been received from Bristol-Myers Squibb, Gilead
Sciences, and GlaxoSmithKline on his behalf.
Kimberly Y. Smith, MD, MPH, has disclosed that she has received consulting
fees from AbbVie, Bristol-Myers Squibb, GlaxoSmithKline/ViiV, Janssen, and
Merck.

6. Initial Therapy: US Guidelines and
Recent Clinical Trials

7. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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DHHS 2013 Guidelines: What to Start
Preferred Regimens
Alternative Regimens
 EFV/TDF/FTC
 EFV + ABC/3TC*
 RPV/TDF/FTC or RPV + ABC/3TC*
Boosted PI
 ATV/RTV + TDF/FTC
 DRV/RTV + TDF/FTC




INSTI
 RAL + TDF/FTC
 RAL + ABC/3TC*
 EVG/COBI/TDF/FTC‡
NNRTI
ATV/RTV + ABC/3TC*
DRV/RTV + ABC/3TC*
FPV/RTV + (TDF/FTC or ABC/3TC*)
LPV/RTV + (TDF/FTC or ABC/3TC*)
*In HLA-B*5701–negative patients with baseline HIV-1 RNA < 100,000 copies/mL.

RPV is not recommended in patients with baseline HIV-1 RNA > 100,000 copies/mL.
‡
EVG/COBI/TDF/FTC should not be started in patients with an estimated CrCl < 70 mL/min.
DHHS Guidelines. February 2013.

8. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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IAS-USA 2012 Guidelines: What to Start
Recommended Regimens
NNRTI
 EFV/TDF/FTC or
 EFV + ABC/3TC*
 ATV/RTV + (TDF/FTC or
Boosted PI
ABC/3TC*)
 DRV/RTV + TDF/FTC
INSTI
 RAL + TDF/FTC
Alternative Regimens
 NVP + (TDF/FTC or ABC/3TC*)
 RPV/TDF/FTC or RPV + ABC/3TC*
 DRV/RTV + ABC/3TC
 LPV/RTV + (TDF/FTC or
ABC/3TC*)
 RAL + ABC/3TC*
 EVG/COBI/TDF/FTC
*In HLA-B*5701–negative patients with baseline HIV-1 RNA < 100,000 copies/mL.
†
Avoiding the use of ABC or LPV/RTV might be considered for patients with or at high risk of
cardiovascular disease.
Thompson MA, et al. JAMA. 2012;308:387-402.

9. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Initial Therapy Options: Important
Differences Between DHHS and IAS-USA
IAS-USA[1]
DHHS[2]
ABC/3TC (with EFV or
ATV/RTV)
“Recommended” (provided BL
HIV-1 RNA < 100k copies/mL)
“Alternative”
NVP (with ABC/3TC or
TDF/FTC)
“Alternative”
“Other”
1. Thompson MA, et al. JAMA. 2012;308:387-402. 2. DHHS Guidelines. February 2013.

10. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Guidelines for Initial Therapy:
Time for a Change?
 In 2009, DHHS listed 4
regimens as “preferred”;
no changes since
Current Preferred Regimens
 Since then, several new
agents have been
approved: RPV,
EVG/COBI, DTG
ATV/RTV
 What do the clinical trials
of these agents show?
NRTIs
Third Agent
EFV
TDF/FTC +
DRV/RTV
RAL

11. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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ECHO/THRIVE: Rilpivirine Noninferior to
Efavirenz Through Wk 96
 More virologic failures with RPV
vs EFV: 14% vs 8%
HIV-1 RNA < 50 c/mL at Wk 96
(ITT-TLOVR)
100
78
80
78
60
– Development of NRTI
mutations more common with
RPV vs EFV
40
20
0
– Difference due to more failures
between Wks 0-48; failures
comparable between arms from
Wks 48-96
n=
686
682
RPV
EFV
Pooled Data
Cohen CJ, et al. AIDS. 2013;27:939-950.
– E138K mutation with RPV →
cross-resistance with ETR
 Discontinuation for AEs more
common with EFV vs RPV: 9%
vs 4%

12. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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ECHO/THRIVE Post Hoc Analysis: Wk 96
Efficacy by Baseline VL and CD4+ Count
Rilpivirine
HIV-1 RNA < 50 copies/mL (%)
100
84
80
80
71
Efavirenz
76
100
73
80
69
65
60
60
40
85
79
56
40
20
71
75
81 79
20
0
n = 368 329
249 270
≤ 100k
69
83
> 100k > 500k
≤ 500k
By Baseline HIV-1 RNA
(copies/mL)
Cohen CJ, et al. AIDS. 2013;27:939-950.
0
n = 34 36
< 50
194 175
313 307
144 164
50 200 ≥ 350
< 200
< 350
By Baseline CD4+ Count
(cells/mm3)

13. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Open-Label STaR Trial: RPV/TDF/FTC
Noninferior to EFV/TDF/FTC at Wk 48

RPV/TDF/FTC noninferior to EFV/TDF/FTC in overall population and in pts
with baseline HIV-1 RNA > 100,000 c/mL
– RPV/TDF/FTC superior to EFV/TDF/FTC in pts with baseline HIV-1 RNA
≤ 100,000 c/mL
RPV/TDF/FTC (n = 394)
Δ: 4.1%
(95% CI: -1.1 to 9.2)
100
86
80
82
Δ : 7.2%
(95% CI: 1.1-13.4)
89
Δ : -1.8%
(95% CI: -11.1 to 7.5)
EFV/TDF/FTC (n = 392)
Post Hoc Analysis
82
80
82
83
82
204/
250
107/
134
116/
142
81/
98
96/
117
72
80
60
40
20
n/N =
0
338/
394
320/
392
All Pts
231/
260
VL ≤ 100k
Cohen C, et al. Glasgow 2012. Abstract O425.
VL > 100k
VL > 100k 500k
26/
36
20/
25
VL > 500k

14. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Summary of Results From Phase III
Studies of RPV vs EFV
 More virologic failures, especially with HIV-1 RNA > 100k[1,2]
– Difference reduced in open-label study, suggesting importance of
adherence, food effect[2]
– DHHS: RPV is not recommended in patients with pretreatment
HIV-1 RNA > 100,000 copies/mL; higher rate of virologic failures
reported in patients with pre-ART CD4+ count < 200 cells/mm 3 who
were treated with RPV + 2 NRTIs[3]
 RPV resistance mutation (E138K) causes cross-resistance with
ETR[1,2]
 Fewer drug discontinuations with RPV than EFV[1,2]
– Fewer rash, CNS events; better lipids[1,2]
1. Cohen CJ, et al. AIDS. 2013;27:939-950. 2. Cohen C, et al. Glasgow 2012. Abstract O425.
3. DHHS Guidelines. February 2013.

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Elvitegravir/Cobicistat/TDF/FTC Noninferior
to Efavirenz/TDF/FTC Through Wk 144
EVG/COBI/TDF/FTC
(n = 348)
Δ: 3.6%
(95% CI: -1.6 to 8.8)
100
80
60
40
20
0
EFV/TDF/FTC
(n = 352)
Δ: 4.9%
(95% CI: -1.3 to 11.1)
Δ: 2.7%
(95% CI: -2.9 to 8.3)
88 84
84
82
80
75

Results consistent across
subgroups: BL HIV-1 RNA, CD4+
count, age, sex, race

Resistance at VF detected in 8 pts
per arm through Wk 48, plus 2
additional pts per arm through
Wk 96—rates similar btwn arms;
no additional pts on EVG/COBI
developed resistance after Wk 96
– In those on EVG/COBI, 9/10 pts
had primary integrase and 10/10
had NRTI resistance mutations
– In those on EFV, 10/10 had NNRTI
and 3/10 had NRTI resistance
mutations
Wk 48
Wk 96
Wk 144
Zolopa A, et al. J Acquir Immune Defic Syndr. 2013;63:96-100. Sax PE, et al. Lancet. 2012;379:2439-2448.
Wohl D, et al. ICAAC 2013. Abstract H-672a.

16. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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EVG/COBI/TDF/FTC Noninferior to
ATV/RTV + TDF/FTC Through Wk 96
EVG/COBI/TDF/FTC
(n = 353)
HIV-1 RNA < 50 c/mL (%)
100
80
ATV/RTV + TDF/FTC
(n = 355)
Δ: 2.7%
Δ: 1.1%
(95% CI: -2.1 to 7.5) (95% CI: -4.5 to 6.7)
90
87
83
82
60
40
 Results consistent across
subgroups: BL HIV-1 RNA,
CD4+ count, adherence, age,
sex, race
 In EVG/COBI arm, resistance at
VF detected in 5 pts through
Wk 48, plus 1 additional pt
through Wk 96 vs 0 pts in
ATV/RTV arm
– 5/6 had primary integrase and
5/6 had NRTI resistance
mutations
20
0
Wk 48
Wk 96
Rockstroh J, et al. J Acquir Immune Defic Syndr. 2013;62:483-486.
De Jesus E, et al. Lancet. 2012;379:2429-2438.

17. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Summary of Results From Tx-Naive
Phase III Studies of EVG/COBI/TDF/FTC
 Virologic outcomes noninferior to EFV/TDF/FTC and ATV/RTV
+ TDF/FTC
– Activity sustained in high VL stratum
 2% failed with resistance, usually to both NRTIs and EVG
 Adverse events
– vs EFV: fewer CNS, rash events; better lipids; more nausea
– vs ATV/RTV: less jaundice
 Small, rapid increase in serum creatinine related to inhibition of
tubular secretion of creatinine
 5 pts (0.7% of total) developed tubulopathy, likely from TDF

18. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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SPRING-2: Dolutegravir QD Noninferior to
Raltegravir BID Through Wk 96
DTG 50 mg QD (n = 411)
RAL 400 mg BID (n = 411)
NRTIs: investigator chosen ABC/3TC (40%) or
TDF/FTC 60%)
HIV-1 RNA < 50 c/mL (%)
100
88
85
80
81
76
60
 DTG noninferior to RAL at
Wk 48[1] and Wk 96[2]
– Response similar with either
NRTI pair and across VL strata
 Adverse events and
discontinuation rates similar
 No resistance at VF with DTG
vs 1 subject with integrase
resistance and 4 with NRTI
resistance in RAL group
40
20
0
Wk 48
Wk 96
Raffi F, et al. Lancet. 2013;381:735-743. Raffi F, et al. IAS 2013. Abstract TULBPE17.

19. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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HIV-1 RNA < 50 c/mL at Wk 48 (%)
SINGLE: DTG + ABC/3TC Superior to
EFV/TDF/FTC at Wk 48
100
Difference 7.4%
(95% CI: +2.5 to +12.3; P = .003)
88
81
80
60
 4% on each arm with protocoldefined VF
 Among pts with VF in EFV
arm, 1 pt with NRTI and 4
with NNRTI resistance vs 0 pts
with resistance in DTG arm
40
20
0
 DTG superior to EFV at Wk 48
primary efficacy endpoint
DTG 50 mg +
ABC/3TC QD
(n = 414)
EFV/TDF/FTC
QD
(n = 419)
Walmsley S, et al. ICAAC 2012. Abstract H-556b.
 Treatment-related study
discontinuation in 10% on EFV
vs 2% on DTG
 CNS events and rash more
common with EFV

20. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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HIV-1 RNA < 50 c/mL at Wk 48 (%)
FLAMINGO: DTG + NRTIs Superior to
DRV/RTV + NRTIs at Wk 48
100
Difference 7.1%
(95% CI: +0.9 to +13.2; P = .025)
90
83
80
 VF: 2 pts (1%) on each arm
60
 No treatment-emergent
resistance in either arm
40
 Treatment-related study
discontinuation in 1% of DTG
pts and 4% of DRV/RTV pts
20
0
 DTG superior to DRV/RTV
(both with TDF/FTC or
ABC/3TC) at Wk 48 primary
efficacy endpoint
DTG 50 mg
QD +
NRTIs
(n = 242)
DRV/RTV
800/100 mg
QD + NRTIs
(n = 242)
Feinberg J, et al. ICAAC 2013. Abstract H1464a.
 More diarrhea with DRV/RTV;
more headache with DTG

21. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Summary of Results From Tx-Naive
Phase III Studies of DTG
 DTG + NRTIs noninferior to RAL + NRTIs; superior to DRV/RTV
+ NRTIs; DTG + ABC/3TC superior to EFV/TDF/FTC
– More drug discontinuations in EFV and DRV/RTV arms
 No DTG resistance mutations as yet detected with virologic
failure
 DTG well tolerated with low rates of study drug discontinuation
– Fewer CNS and rash events compared with EFV
– Less diarrhea than DRV/RTV
 Small rapid increase in serum creatinine related to inhibition of
tubular secretion of creatinine
– No drug-related renal events

22. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Dolutegravir Approval—August 2013
 Dolutegravir is indicated in combination with other
antiretroviral agents for the treatment of HIV-1 infection in
adults and children aged 12 yrs and older and weighing at
least 40 kg
– Dolutegravir 50 mg QD in treatment-naive or INSTI-naive
treatment-experienced patients
– Dolutegravir 50 mg BID in INSTI-experienced patients or
when administered with certain UGT1A/CYP3A inducers
 Not yet included in guidelines
Dolutegravir [package insert].

23. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Potential Benefits of New Treatment
Options for HIV
Rilpivirine
 Smallest single-tablet
regimen
 Fewer CNS and rash
events vs EFV
 Better lipids than EFV
 Superior to EFV if HIV-1
RNA < 100k
Elvitegravir/Cobicistat
Dolutegravir
 Single-tablet regimen
 Maintains comparable
virologic activity to EFV,
ATV across low and high
HIV-1 RNA
 Fewer CNS and rash
events vs EFV
 Better lipids than EFV,
comparable to ATV/RTV
 Less jaundice than
ATV/RTV
 Superior to EFV/TDF/FTC
and DRV/RTV
 Maintains at least
comparable virologic
activity to EFV, RAL,
DRV/RTV across low and
high HIV-1 RNA
 Fewer CNS and rash
events vs EFV
 Better lipids than EFV
 No resistance detected
with virologic failure
 Fewer drug–drug
interactions than boosted
PIs, EVG/COBI

24. Making the Match

25. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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2013 Recommendations for ART Initiation
 ART is recommended for all HIV-infected ART-naive pts
to reduce risk of disease progression and transmission
– Strength of recommendation varies by CD4+ cell count and
risk group (perinatal, heterosexual, other)
– Pts should be ready to commit to ART and understand
benefits and risks of therapy and importance of adherence;
individual pts may elect to defer ART
 Selection of a regimen should be individualized on the
basis of virologic efficacy, toxicity, pill burden, dosing
frequency, drug–drug interaction potential, resistance
testing results, and comorbid conditions
DHHS Guidelines. February 2013.

26. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Considerations When Selecting First-line
Antiretroviral Therapy
Patient/Viral Factors
 Baseline CD4+ cell count/
HIV-1 RNA level
Age
Sex
Occupation (eg, work
schedule)
 Comorbid conditions (eg, CV
risk, renal abnormalities)
Plans for pregnancy
Access to care
Concurrent medications
Adherence to other
medications
Genetics (eg, HLA-B*5701)
Viral tropism
Antiretroviral Drug Factors
Efficacy
 Baseline drug resistance
Tolerability
 Long-term toxicity/metabolic
effects
Drug–drug interactions
Dosing frequency
Pill burden
Pharmacokinetics
Cost

27. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for EFV?
Considerations in Favor
Considerations Against
 Coformulation; 1 pill QD[1]
 High risk of resistance at
virologic failure[3]
 Effective across HIV-1 RNA,
CD4+ strata[2]
 CNS effects[1]
 Most experience of all
NNRTIs
 Potential for teratogenesis in
early pregnancy[4]
 Most experience of all
preferred drugs
 Drug–drug interactions with
other drugs metabolized by
CYP system[1]
 Increases in lipids[5]
1. TDF/FTC/EFV [package insert]. 2. Ribaudo HJ, et al. J Infect Dis. 2008;197:1006-1010. 3. Gallant J, et
al. N Engl J Med. 2006;354:251-260. 4. DHHS Perinatal Guidelines. July 2012. 5. Daar E, et al. Ann
Intern Med. 2011;154:445-456.

28. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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DHHS Guidelines: Using EFV in Pts Who
Are (or Are Likely to Become) Pregnant
 ARV regimens that do not include EFV should be
strongly considered in women who
– Are planning to become pregnant or
– Are sexually active and not using effective contraception
 Avoid initiation of EFV or other potentially teratogenic
drugs in the first trimester and drugs with known adverse
potential for mother throughout the pregnancy
 EFV may be continued in pregnant women receiving an
EFV-based regimen who present for antenatal care in the
first trimester, provided there is virologic suppression on
the regimen
DHHS Perinatal Guidelines. July 2012.

29. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for Boosted PIs?
Considerations in Favor
Considerations Against
 Effective across HIV-1 RNA,
CD4+ strata[1,2]
 No coformulations with NRTIs
 Few CNS adverse events[1,2]
 Little/no emergence of
resistance at VF[1,2]
 Preferred agents in pregnancy
(ATV/RTV, LPV/RTV)[3]
 Low risk for new resistance
to develop in those with
transmitted resistance
 Variable lipid effects[1,2]
 Concerns about renal function
(greatest concern when
ATV/RTV combined with TDF)[1,4]
 Drug–drug interactions with
other drugs metabolized by CYP
system[5,6]
 Hyperbilirubinemia with ATV[1,5]
1. Molina JM, et al. Lancet. 2008;372:646-655. 2. Ortiz R, et al. AIDS. 2008;22:1389-1397. 3. DHHS Perinatal Guidelines.
July 2012. 4. Mocroft A, et al. AIDS. 2010;24:1667-1678. 5. Atazanavir [package insert]. 6. Darunavir [package insert].

30. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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DHHS Guidelines on ART for Patients With
Early Infection
 Patients with early infection should be offered ART
– “Early” HIV infection now refers to acute (after infection, prior
to seroconversion) and recent (< 6 mos) infections
– Choice of regimen should be among those recommended for
patients with chronic disease
– ART can be initiated before drug resistance test results are
available; if so, a boosted PI + 2 NRTIs should be chosen
DHHS Guidelines. February 2013.

31. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for RAL?
Considerations in Favor
Considerations Against
 Effective across HIV-1 RNA,
CD4+ strata[1]
 No coformulations with
NRTIs
 Few adverse events[1]
 Twice-daily dosing[2,4]
 Few drug–drug interactions[2]
 High risk of resistance at VF[3]
 Limited effects on lipids[3]
 Most experience of all
INSTIs
1. Rockstroh J, et al. J Acquir Immune Defic Syndr. 2013;63:77-85. 2. Raltegravir [package insert].
3. Lennox J, et al. Lancet. 2009;374:796-806. 4. Eron JJ Jr, et al. Lancet Infect Dis. 2011;11:907-915.

32. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for TDF/FTC?
Considerations in Favor
Considerations Against
 Effective across HIV-1 RNA,
CD4+ strata[1]
Associated with decreases
in renal function[4]
 Not shown to be associated
with MI in D:A:D[2]
Associated with greater
decreases in BMD[5]
 Coformulations with EFV,
EVG, RPV
 Active against HBV[3]
1. Sax P, et al. N Engl J Med. 2009;361:2230-2240. 2. Worm S, et al. J Infect Dis. 2010; 201:318-330.
3. DHHS Guidelines. February 2013. 4. Gallant J, et al. AIDS. 2008;22:2155-2163. 5. McComsey G, et
al. J Infect Dis. 2011;203:1791-1801.

33. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for ABC/3TC?
Considerations in Favor
Considerations Against
No specific association with
decreases in renal function
 No current coformulations
Less decrease in BMD than with
TDF[1]
 Less effective at HIV-1 RNA
> 100,000 with EFV and
ATV/RTV[2]
 Associated with acute MI in
some studies[3-5]
 Requirement for HLA-B*5701
test before use[6]
 Not optimal as lone NRTI pair in
HBV-coinfected pts
1. McComsey G, et al. J Infect Dis. 2011;203:1791-1801. 2. Sax P, et al. N Engl J Med. 2009;361:2230-2240. 3. Worm
S, et al. J Infect Dis. 2010; 201:318-330. 4. Martin A, et al. Clin Infect Dis. 2009;49:1591-1601. 5. Durand M, et al. J
Acquir Immune Defic Syndr. 2011;57:245-253. 6. ABC/3TC [package insert].

34. What About the Newer Drugs?

35. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for RPV?
Considerations in Favor
Considerations Against
Coformulated/1 pill daily
Superior vs EFV at lower VL[1]
Fewer CNS adverse events
than EFV[2]
 Less effective at high BL VL[2]
(not recommended at high
VL and low CD4+)[3]
 Food requirement[4]
 Restricted use with PPIs or
H2 blockers[4]
 High risk of resistance and
cross-resistance with other
NNRTIs at VF[2]
1. Cohen C, et al. Glasgow 2012. Abstract O425. 2. Cohen C, et al. AIDS. 2013;27:939-950.
3. DHHS Guidelines. February 2013. 4. TDF/FTC/RPV [package insert].

36. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for TDF/FTC/EVG/COBI?
Considerations in Favor
Considerations Against
 Coformulated/1 pill dally
 Includes pharmacologic
booster
 Once-daily INSTI regimen
 Noninferior to EFV and
ATV/RTV across HIV-1 RNA,
CD4+ strata[1,2]
 Fewer CNS AEs than EFV[1]
 High risk of resistance at VF[14]
 Cross resistance with RAL[5]
 Drug–drug interactions[6]
 Concerns about monitoring
renal function with COBI[6]
1. Zolopa A, et al. J Acquir Immune Defic Syndr. 2013;63:96-100. 2. Rockstroh J, et al. J Acquir Immune Defic
Syndr. 2013;62:483-486. 3. Sax PE, et al. Lancet. 2012;379:2439-2448. 4. DeJesus E, et al. Lancet. 2012;379:24292438. 5. DeJesus E, et al. IAS 2007. Abstract TUPEB032. 6. TDF/FTC/EVG/COBI [package insert].

37. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Which Patient for DTG?
Considerations in Favor
Considerations Against
 Once-daily INSTI without
boosting
 Not yet available as
coformulation
 Superior efficacy vs EFV and
DRV/RTV[1,2]
 Concerns about monitoring
renal function[4]
 Potentially less resistance at
VF[1,3]
 No guideline recommendation
at this time
 Effective at high VL with both
ABC/3TC and TDF/FTC[3]
 Well tolerated[1-3]
 Few drug–drug interactions[4]
1. Walmsley S, et al. ICAAC 2012. Abstract H-556b. 2. Feinberg J, et al. ICAAC 2013. Abstract H1464a. 3. Raffi F, et al. Lancet. 2013;381:735-743. 4. Dolutegravir [package insert].

38. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Individualizing First-line Therapy:
Specific Circumstances
Circumstance
Agents
No genotype
 Use boosted PI
High HIV-1 RNA
 Caution with ABC, RPV
Renal disease
 Caution with TDF, ATV/RTV; monitoring complicated with
COBI and DTG
Dyslipidemia
 RAL, DTG, RPV most lipid neutral
CV risk factors
 Possible association with ABC, ddI, LPV/RTV
 No data for DRV/RTV, INSTIs, MVC
Pregnancy
 Preferred: ZDV/3TC + NVP, LPV/RTV, or ATV/RTV
 EFV can be used after first 5-6 wks
Chronic HBV infection
 Preferred TDF + 3TC or FTC
 Alternative is entecavir
Decreased BMD
 Caution with TDF
Concerns about CNS effects
 Caution with EFV for at least first mo

39. Managing Patients Receiving
First-line Therapy

40. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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What’s New in the Guidelines With
Laboratory Tests
 Repeat HIV serology at entry into care if diagnosis not
confirmed
 Obtain HCV serology at entry into care and when clinically
indicated
 A genotypic viral tropism test is now available, but the
phenotypic test is preferred
 At VF of an INSTI-based regimen, an integrase genotypic
resistance assay should be obtained
DHHS Adult Guidelines. February 2013.

41. Adverse Events

42. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Low Discontinuation for AEs in Clinical
Trials With Preferred and Newer Agents
Agent
EFV (ACTG 5202)[1]
Discontinuation Rate for AEs by Wk 48 in
Major Clinical Trials, %
9 (TDF/FTC arm)
ATV/RTV (CASTLE)[2]
2
DRV/RTV (ARTEMIS)[3]
3
RAL (STARTMRK)[4]
3
RPV (ECHO)[5]
2
EVG/COBI (GS102)[6]
4
DTG (SINGLE)[7]
2
1. Daar E, et al. Ann Intern Med. 2011;154:445-456. 2. Molina JM, et al. Lancet. 2008;372:646-655.
3. Ortiz R, et al. AIDS. 2008;22:1389-1397. 4. Lennox J, et al. Lancet. 2009;374:796-806.
5. Molina JM, et al. Lancet. 2011;378:238-246. 6. Sax P, et al. Lancet. 2012;379:2439-2448.
7. Walmsley S, et al. ICAAC 2012. Abstract H-556b.

43. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Most Common Adverse Events Expected
With Newer Drugs
Most Common AEs
RPV[1]
 Depressive disorders
 Headache
 Insomnia
 Rash
TDF/FTC/EVG/COBI[2]
 Nausea
 Diarrhea
 Abnormal dreams
DTG[3]
 Insomnia
 Headache
1. Rilpivirine [package insert]. 2. TDF/FTC/EVG/COBI [package insert]. 3. Dolutegravir [package insert].

44. Drug–Drug Interactions

45. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Drug–Drug Interactions With First-line
ART and Lipid-Lowering Therapy
Antiretroviral
Contraindicated
Titrate Dose
RPV[1]
EVG/COBI/TDF/
FTC[1]
No Dose Adjustment
Atorvastatin
Lovastatin
Simvastatin
Atorvastatin
Rosuvastatin
ATV/RTV[1]
Lovastatin
Simvastatin
Atorvastatin
Rosuvastatin
Pitavastatin
DRV/RTV[1]
Lovastatin
Simvastatin
Atorvastatin
Pravastatin
Rosuvastatin
Pitavastatin
DTG[2]
EFV[1]
Atorvastatin
Simvastatin
Pravastatin
Rosuvastatin
RAL[1]
1. DHHS Adult Guidelines. February 2013. 2. Dolutegravir [package insert].

46. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Drug–Drug Interactions With OCPs
Antiretroviral
Effect on OCP
Dosing Recommendation
Ethinyl estradiol AUC ↑ 14%
Norethindrone: no significant change
No dose adjustment
Ethinyl estradiol AUC ↓ 25%
Norgestimate ↑
No clinically relevant interaction
Weigh the risks and benefits of norgestimate
↑ and consider alternative contraceptive
ATV/RTV[1,2]
Ethinyl estradiol AUC ↓
Norgestimate ↑
OCP should contain ≥ 35 mcg ethinyl
estradiol
DRV/RTV[1,2]
Ethinyl estradiol AUC ↓ 44%
Norethindrone AUC ↓ 14%
No effect on ethinyl estradiol
Active metabolites of norgestimate ↓
Additional methods of contraception
recommended
RPV[1,2]
EVG/COBI
TDF/FTC[1,3]
DTG[4]
EFV[1,2]
RAL[1,2]
No clinically relevant interaction
No dose adjustment
A reliable method of barrier contraception
must be used in addition to hormonal
contraceptives
No dose adjustment
1. DHHS Adult Guidelines. February 2013. 2. DHHS Perinatal Guidelines. July 2012.
3. TDF/FTC/EVG/COBI [package insert]. 4. Dolutegravir [package insert].

47. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Drug–Drug Interactions With BOC and
TVR
Antiretroviral
Interactions With Boceprevir
Interactions With Telaprevir
No clinically relevant interactions
No clinically relevant interactions
No data
No clinically relevant interactions
No clinically relevant interactions
No clinically relevant interactions
ATV/RTV[5]
Coadministration not
recommended
Coadministration not recommended
DRV/RTV[5]
Coadministration not
recommended
Coadministration not recommended
EFV[5]
Coadministration not
recommended
Increase TVR dose to 1125 mg q8h
RAL[5]
No clinically relevant interactions
No clinically relevant interactions
RPV[1,2]
EVG/COBI
TDF/FTC[3]
DTG[4]
1. Rhee E, et al. CROI 2013. Abstract 537. 2. Rilpivirine [package insert]. 3. Custodio J, et al. ICAAC 2013.
Abstract A-1576. 4. Dolutegravir [package insert]. 5. DHHS Adult Guidelines. February 2013.

48. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Drug–Drug Interactions With AcidReducing Medications and Newer ARVs
ARV
Antacids
H2-Receptor
Antagonists
Proton Pump
Inhibitors
Give antacids at least
2 hrs before or at
least 4 hrs after RPV
Give H2-receptor
antagonists at least 12 hrs
before or at least 4 hrs
after RPV
Contraindicated
EVG/COBI
TDF/FTC[1]
Separate EVG/COBI/
FTC/TDF and antacid
administration by > 2 hrs
No clinically relevant
interactions
No clinically relevant
interactions
DTG[2]
DTG should be given
2 hrs before or 6 hrs after
taking medications
containing polyvalent
cations
RPV[1]
1. DHHS Adult Guidelines. February 2013. 2. Dolutegravir [package insert].
No clinically relevant
interactions

49. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Drug–Drug Interactions Between RTVBoosted PIs and Steroid Preparations
 Steroid preparations should be given with caution with
boosted PIs, regardless of administration route
 Coadministration can result in adrenal insufficiency,
including Cushing’s syndrome; coadministration is not
advised unless potential benefits outweigh the risks
DHHS Adult Guidelines. February 2013.

50. Managing ART in Pts Who
Become Pregnant on Therapy

51. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Changes in Perinatal Guidelines—2012
 The Panel recommends that EFV be continued in
pregnant women receiving EFV-based ART who present
for antenatal care in the first trimester, provided the
regimen is resulting in virologic suppression (CIII)
 Pregnant women receiving and tolerating NVP-containing
regimens who are virologically suppressed should
continue the regimen, regardless of CD4+ cell count (AIII)
DHHS Perinatal Guidelines. July 2012.

52. Lipids

53. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Lipid Comparisons in Clinical Trials
ARV
Comparisons
RPV[1]
vs EFV at Wk 48
Smaller changes in TC, HDL-C, LDL-C, TG (all P < .0001)
COBI[2]
vs RTV at Wk 48 when combined with ATV
Similar changes in lipids in all fractions
EVG/COBI
TDF/FTC[3-5]
vs EFV at Wk 48
Smaller changes in TC (P < .001), HDL-C, LDL-C (both P = .001)
Similar changes in TG between arms
vs ATV/RTV at Wk 48
Similar changes in TC, HDL-C, LDL-C
Smaller change in TG (P = .006)
DTG[6]
vs RAL at Wk 48
Similar small changes in lipids in all fractions
vs EFV at Wk 48
Smaller changes in TC, HDL-C, LDL-C
1. Cohen C, et al. AIDS. 2013;27:939-950. 2. Gallant J, et al. J Infect Dis. 2013;208:32-39. 3. Sax P, et al. Lancet.
2012;379:2439-2448. 4. DeJesus E, et al. Lancet. 2012;379: 2429-2438. 5. Sax P, et al. CROI 2012. Abstract 101.
6. Dolutegravir [package insert].

54. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Lipid and Efficacy Data in Recent Switch
Studies
 SPIRIT: Switch boosted PI to RPV vs remain on boosted
PI
– BL to Wk 48: improvement in mean fasting TC, LDL-C, TG,
and TC:HDL-C ratio
– Switching noninferior to continuing boosted PI regimen at
Wk 24
– Noninferiority maintained at Wk 48 but 5 additional cases of VF
between Wks 24 and 48
Fisher M, et al. Glasgow 2012. Abstract P285.

55. Renal

56. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Change From BL in Serum Creatinine
(mg/dL; IQR)
EVG/COBI/TDF/FTC vs EFV or ATV/RTV:
Creatinine Changes

0.35
0.30
EVG/COBI/TDF/FTC
EFV/TDF/FTC
0.28
0.24
0.25
EVG/COBI/TDF/FTC
ATV/RTV + TDF/FTC
0.20
0.20
0.16
0.15
0.12
0.10
0.08
0.05
0
0.04
-0.05
0
-0.10
-0.04
BL 2 4 8 12 16
24
Wks
32
40
48
BL 2 4 8 12 16
24
Wks
32
40
48
Cobicistat is associated with reduced active secretion of creatinine in the renal
tubules leading to initial rises in creatinine levels
Sax P, et al. Lancet. 2012;379:2439-2448. DeJesus E, et al. Lancet. 2012;379:2429-2438.

57. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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SPRING-2: Changes in Serum Creatinine
and Creatinine Clearance
DTG 50 mg QD (n = 411)
RAL 400 mg BID (n = 411)
0.28
0.22
0.17
+0.14
0.11
+0.05
0.06
10
0
10
-20
0
-30
0.06
2 4
8
12 16
24
Wk
32
40
48
Baseline (mg/mL): DTG 0.85 vs RAL 0.85

Change in CrCl, Mean (± SD)[2]
Mean Change From Baseline
(mL/min)
Mean Change From Baseline
of Creatinine (mg/dL)
Change in Serum Creatinine, Mean (± SD)[1]
BL
4
12
24
Wk
48
Baseline (mL/min): DTG 125 vs RAL 128
DTG increases serum creatinine by the benign inhibition of the organic cation
transporter 2, which is responsible for tubular secretion of creatinine[3]
1. Raffi F, et al. Lancet. 2013;381:735-743. 2 Raffi F, et al. AIDS 2012. Abstract THLBB04. 3. Koteff J, et
al. Br J Clin Pharmacol. 2013;75:990-996.

58. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Special Considerations for Monitoring
Renal Function
 Some drugs have an effect on creatinine including cimetidine,
cobicistat, trimethoprim, RPV, and DTG
– Expected minor increases in creatinine and decreases in
estimated CrCl during treatment with these agents do not reflect
changes in actual CrCl
 Baseline CrCl < 70: do not use EVG/COBI/TDF/FTC
– Stop if estimated CrCl < 50 (cannot adjust dose)
 Pts at risk of renal disease: monitor urine protein, glucose,
serum phosphorus, and CrCl
– Confirmed rise in serum creatinine of > 0.4 mg/dL is considered
significant

59. First and Foremost: Choosing and Using First-line Antiretroviral Therapy
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Summary
 Several excellent options for first-line ART
– Safety and tolerability continues to improve
– Important differences in drug–drug interactions
 Individualize selection and monitoring and plan for longterm success