Table 5.
Advantages and Disadvantages of Initial Antiretroviral Therapy Options for Patients in Whom InSTIs Are Not an Optiona
| Darunavir (Boosted With Cobicistat or Ritonavir) Plus TAF/Emtricitabine, TDF/Emtricitabine, or Abacavir/Lamivudineb |
Efavirenz/TDF/Emtricitabine | Rilpivirine/TAF (or TDF)/Emtricitabine | |
|---|---|---|---|
| Advantages | Low risk of resistance with virologic failure, even with intermittent adherence |
High efficacy in patients with baseline HIV RNA >100 000 copies/mL Extensive experience in patients with concomitant tuberculosis Widely available globally |
Lowest risk of rash among NNRTI-based therapies Low risk of metabolic adverse effects Smallest tablet among single-pill regimens |
| Disadvantages | Requires pharmacokinetic boosting; many drug interactions Ritonavir-boosted darunavir inferior to raltegravir and dolutegravir in separate comparative clinical trials37,39 Results of comparative, fully powered studies of cobicistat-boosted darunavir as initial therapy are not yet available |
Relatively high rate of rash No single-tablet form available with TAF High rates of neuropsychiatric adverse effects Increased risk of suicidality in 1 study55; avoid in patients with history of depression |
Not recommended for patients with HIV RNA >100 000 copies/mL or CD4 cell count <200/µL owing to increased risk of virologic failure Must be taken with a meal to optimize absorption Should not be administered with proton pump inhibitors; stagger dosing if given with an H2 blocker |
Abbreviations: InSTI, integrase strand transfer inhibitor; NNRTI, nonnucleoside reverse transcriptase inhibitor; TAF, tenofovir alafenamide; TDF, tenofovir disoproxil fumarate.
a
Nonnucleoside reverse transcriptase inhibitor–based regimens should not be used without baseline resistance data because of the possible presence of transmitted NNRTI-resistant virus. In the rare circumstance in which maraviroc might be included in initial therapy, initiation should not occur before confirmation of CC chemokine receptor 5 tropism.
b
Cautions on the use of abacavir and TAF or TDF are described in the text.