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Am Fam Physician. 2011;84(12):1

Original Article: Common Adverse Effects of Antiretroviral Therapy for HIV Disease
Issue Date: June 15, 2011
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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.

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 (

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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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