Antiretroviral Guidelines

US DHHS Guidelines with Australian commentary

Optimizing Antiretroviral Therapy in the Setting of Virologic Suppression

Last Updated: December 18, 2019; Last Reviewed: December 18, 2019

Panel's Recommendations for Optimizing Antiretroviral Therapy in the Setting of Virologic Suppression

AU comment: Long-Acting Injectable Cabotegravir and Rilpivirine in Persons with HIV

AU comment: Change in classification of regimens

AU comment: RTV-Boosted PI Monotherapy

Panel’s Recommendations

  • Advances in antiretroviral (ARV) treatment and a better understanding of HIV drug resistance make it possible to consider switching a person with HIV from an effective regimen to an alternative regimen in some situations.
  • The fundamental principle of regimen optimization is to maintain viral suppression without jeopardizing future treatment options.
  • Adverse events, drug-drug or drug-food interactions, pill burden, pregnancy, cost, or the desire to simplify a regimen may prompt a regimen switch.
  • It is critical to review a patient’s full ARV history, including virologic responses, past ARV-associated toxicities and intolerances, and cumulative resistance test results, before selecting a new antiretroviral therapy regimen (AI).
  • Monotherapy with either a boosted protease inhibitor or an integrase strand transfer inhibitor has been associated with unacceptable rates of virologic failure and the development of resistance; therefore, monotherapy as a switch strategy is not recommended (AI).
  • When switching an ARV regimen in a person with hepatitis B virus (HBV)/HIV coinfection, ARV drugs that are active against HBV infection should be continued (AII). Using 3TC or FTC as the only drug in a regimen with HBV activity is not recommended (AII), as HBV resistance to these drugs can emerge. Discontinuation of HBV drugs may lead to reactivation of HBV, which may result in serious hepatocellular damage.
  • Consultation with an HIV specialist is recommended when planning a regimen switch for a patient with a history of resistance to one or more drug classes (AIII).
  • Close monitoring to assess tolerability, viral suppression, adherence, and safety is recommended during the first 3 months after a regimen switch (AIII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion