Patient and Treatment Characteristics for HIV Therapy
Patient Characteristics
Pre-therapeutic Considerations
When it comes to initiating HIV treatment, understanding the patient’s unique characteristics is crucial. Among the primary considerations is the stage of infection:
- Primo-infection: Treatment should start quickly.
Recommended Treatment Combinations
Preferential Choices:
- TAF/FTC/BIC
- TDF/FTC + DTG
Alternative Choices:
- TDF/FTC + DRV/r
Immediate Treatment Initiation
Rapid initiation of treatment before the results of genotypic resistance testing is critical. Avoid combinations with:
- RPV
- RAL (due to resistance frequency)
High viral load scenarios (CV >100,000 copies/mL) may lead to greater risks of virological failure with RPV as well. Thus, certain combinations should be avoided:
- 3TC/DTG or TDF/3TC/DOR (insufficient efficacy data if CV >500,000 copies/mL)
Other Important Factors
- If the patient is HLA B*5701 positive or has an unknown status, avoid ABC due to the risk of hypersensitivity reactions.
- Treatment should be initiated promptly, with careful selection of medications based on viral load and CD4 counts.
Treatment Characteristics
Single Daily Tablet Regimen
Taking a single tablet daily is ideal for adherence. Here are the recommended combinations:
- TAF/FTC/BIC
- TDF/3TC/DOR
- ABC/3TC/DTG
- 3TC/DTG
- TAF/FTC/RPV
Diet Considerations
Dietary Flexibility:
The following combinations are not affected by food intake:
- Based on BIC, DOR, DTG, or RAL
Food Requirement:
Take the combinations based on:
- DRV/r with food
- Oral RPV with food
Management of Comorbidities and Special Situations
Chronic Kidney Failure
Avoid TDF in patients with chronic kidney failure (GFR < 30 mL/min/1.73m²). TAF can be considered if GFR >30 mL/min/1.73m² or during hemodialysis.
Weight Management
For patients with overweight or who are at risk for weight gain:
- Favor NNRTI combinations (DOR or RPV).
- Prefer TDF or ABC over TAF.
Bone Health
In patients with osteoporosis, avoid TDF, particularly when combined with RTV.
Neuropsychiatric Disorders
Exercise caution with BIC, DTG, RAL, DOR, and RPV, as these may carry risks of psychiatric adverse effects.
Cardiovascular Risk
Avoid DRV/r in patients with a high cardiovascular risk. Discuss the potential benefits and risks associated with ABC use.
Coinfections Considerations
Hepatitis B Virus (HBV)
For patients with HBV, use combinations such as TDF/FTC or TAF/FTC. If necessary, add entecavir to the ARV regimen:
- Be cautious: Stopping active HBV treatment can lead to serious complications.
Hepatitis C Virus (HCV)
Evaluate potential drug interactions between ARVs and direct-acting anti-HCV antivirals.
Tuberculosis Treatment
In cases of TB treated with rifampicin or rifabutin, consider the following combinations:
| Combination | With Rifampicin | With Rifabutin |
|---|---|---|
| ABC/3TC/DTG | Yes | Yes |
| TDF/FTC + DTG | Yes | Yes |
| ABC/3TC + RAL | Yes | Yes |
| TDF/FTC + RAL | Yes | Yes |
| DTG Dosage | 50 mg x 2/day (for 2 weeks after stopping rifampicin) |
Refer to specific treatment guidelines to adapt ARV treatment as needed to ensure efficacy and patient safety.
