Letters to the Editor

Antiretroviral Therapy Regimens in Treatment-Naive Patients



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Am Fam Physician. 2011 Dec 15;84(12):online.

Original Article: Common Adverse Effects of Antiretroviral Therapy for HIV Disease

Issue Date: June 15, 2011

Available at: http://www.aafp.org/afp/2011/0615/p1443.html

to the editor: I would like to commend Dr. Reust on a well-written, informative article, which I felt was very helpful in describing common adverse effects of antiretroviral therapy. However, I am concerned that Figure 1 is misleading in its representation of the preferred and alternative regimens for antiretroviral therapy-naive patients. The text of the article accurately states that “the most common initial regimens are a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI) with two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs).” However, Figure 1 implies that two drug regimens are recommended; this is not the case for treatment-naive patients; and is usually avoided, if possible, in treatment-experienced patients. Antiretroviral therapy in treatment-naive patients should always include at least three active agents against human immunodeficiency virus. Also, ritonavir (Norvir) is not recommended as a single agent for treatment-naive patients, as implied by the figure; it is used in the recommended regimens only for boosting the levels of the protease inhibitor, as mentioned in the text of the article. Essentially, the NRTI backbone for the preferred regimens consists of tenofovir (Viread) and emtricitabine (Emtriva), plus either an NNRTI (e.g., efavirenz [Sustiva]), boosted PI (e.g., atazanavir/ritonavir or darunavir/ritonavir), or integrase strand transfer inhibitor (raltegravir [Isentress]). I would refer readers to Table 5a in the U.S. Department of Health and Human Services guidelines,1 which were updated January 10, 2011, for a clearer description of the recommended preferred and alternative regimens for treatment-naive patients.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCES

1. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. January 10, 2011. http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=7&ClassID=1. Accessed July 7, 2011.

in reply: In addition to Dr. Schwartz, many other readers of American Family Physician (AFP) as well as myself contacted the journal with concerns about this figure. In my original manuscript, it was submitted correctly; however, during the production process the plus sign (+) was replaced with the word “or,” which resulted in the regimens appearing to be two-drug regimens instead of three-drug regimens. A correction to the online version of the article and the online PDF was made within 24 hours of publication, and a subsequent correction was published in the July 15 edition of AFP (http://www.aafp.org/afp/2011/0715/p154.html).

Dr. Schwartz is correct that antiretroviral therapy uses three active agents. As he noted, full-strength ritonavir (Norvir), 600 mg twice a day, is not a first-line therapy. However, it is used in a boosted format (in a dose of 100 mg) with other protease inhibitors. The correct Figure 1 shows protease inhibitor regimens that include ritonavir plus atazanavir, ritonavir plus darunavir, ritonavir plus fosamprenavir or ritonavir combined with lopinavir.

Author disclosure: No relevant financial affiliations to disclose.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.



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