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Key Principles and Recommended Regimens for First-line Antiretroviral Therapy

Joseph J. Eron, Jr., MD
Program Director
Daniel R. Kuritzkes, MD
Program Director
Paul E. Sax, MD
Released: June 11, 2020

Pretherapy Antiretroviral Resistance Testing

Genotypic resistance testing for reverse transcriptase and protease mutations is recommended for all patients newly diagnosed with HIV infection, even if treatment is not immediately initiated.[1,2,8] Resistance testing for transmitted INSTI resistance should be performed if transmitted INSTI resistance is a concern.[1] Genotypic resistance testing of ARV-naive patients has been shown to be cost-effective compared with other HIV care.[9] The CDC has reported that the proportion of newly infected individuals who are infected with a drug-resistant strain of HIV has remained steady at approximately 16%,[10] but ongoing surveillance and monitoring is important. Among the patterns of resistance observed, the most clinically important is NNRTI resistance, with several studies showing a significantly higher rate of virologic failure for NNRTI-based regimens when such resistance is identified at baseline.[11,12]

In the absence of baseline resistance, several features distinguish boosted PI–based, NNRTI-based, and INSTI-based therapies. The next pages review how and when to choose regimens of each type, taking into account information from clinical trials that demonstrated efficacy and safety of the various first-line regimens. First-line regimens should consider patient and regimen factors including dosing, adverse events, comorbidities, and other medications that the patient may be taking.

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