The drug combinations used for highly active antiretroviral therapy (HAART) to treat HIV infection have grown markedly in the past 5 years. There are theoretical advantages and disadvantages to combination therapy based on a single protease inhibitor (PI), ritonavir (RTV) plus saquinavir (SQV), or efavirenz (EFV). However, a recent clinical trial demonstrated that initial EFV-based combination antiretroviral therapy was associated with higher rates of HIV suppression than PI-based therapy. A new study based on 545 HIV-infected individuals treated at an urban HIV clinic came to the same conclusion.
In a study that was supported in part by the Agency for Healthcare Research and Quality (HS07809), Richard D. Moore, M.D., and colleagues at the Johns Hopkins University School of Medicine compared the virologic and immunologic effectiveness of initial combination therapy with nucleoside reverse transcriptase inhibitors plus either: a single PI; RTV/SQV; or EFV (all but PI are non-nucleoside reverse transcriptase inhibitors). They examined HIV-infected patients with little previous exposure to HAART for a change in the number of copies of HIV RNA within 8 months and a change in CD4 cell count within 12 months of starting therapy.
Nearly three-fourths (72 percent) of patients in the EFV group achieved initial viral suppression (less than 400 HIV RNA copies/ml) compared with 49 percent in the single PI group and 51 percent in the RTV/SQV group. Among patients who achieved initial viral suppression, time to viral rebound (greater than 1,000 HIV RNA copies/ml) was similar in the three groups. Durable viral suppression (three or more consecutive HIV RNA levels less than 400 copies/ml for more than 6 months) was achieved by 53 percent of patients in the EFV group, 26 percent in the single PI group, and 29 percent in the RTV/SQV group.
In this clinic, the probability of HIV disease progression or death was 18 percent in patients who did not achieve viral suppression versus 9 percent in patients who did. The median CD4 cell count increase was 139 x 106 cells/l and was similar in the three groups.
See "Comparison of initial combination antiretroviral therapy with a single protease inhibitor, ritonavir and saquinavir, or efavirenz," by Gregory M. Lucas, M.D., Richard E. Chaisson, M.D., and Dr. Moore, in the September 2001 AIDS 15(13), pp. 1679-1686.
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