To the Editor As HIV clinicians, we read with interest the new antiretroviral treatment guidelines published on behalf of the International Antiviral Society–USA.1 Nevertheless, we believe these guidelines failed to integrate emerging evidence and may have reflected implicit commercial bias.
Our first concern revolves around the primacy of the integrase strand transfer inhibitor (InSTI) class as the foundation of recommended initial HIV regimens. Since their early use in treatment-naive patients, the primary advantage of InSTIs over other antiretroviral classes was their favorable adverse effect profile rather than superior virological efficacy. The long-term safety profile of the InSTI drug class is now being reconsidered because disproportionate weight gain and treatment-emergent obesity have been observed in randomized clinical trials2,3 and retrospective analyses.4 We believe it is time to return to an older treatment regimen, one that includes nonnucleoside reverse transcriptase inhibitors and protease inhibitors in the initial regimens recommended for the treatment of HIV.
Shalev N, Brudney KF, Scherer ML. Antiretroviral Drug Recommendations for HIV Treatment and Prevention. JAMA. 2021;325(9):888–889. doi:10.1001/jama.2020.25987
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