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Original Investigation
Sep 24, 2012

Choice of Initial Combination Antiretroviral Therapy in Individuals With HIV Infection: Determinants and Outcomes

Author Affiliations

Author Affiliations: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel (Drs Elzi, Erb, and Battegay); University Clinic for Infectious Diseases, University Hospital Bern and University of Bern (Dr Furrer); Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich (Drs Ledergerber and Weber); Division of Infectious Diseases, University Hospital Lausanne (Dr Cavassini); Division of Infectious Diseases, University Hospital Geneva (Dr Hirschel); Division of Infectious Diseases, Cantonal Hospital S. Gallen (Dr Vernazza); and Division of Infectious Diseases, Regional Hospital Lugano (Dr Bernasconi), Switzerland. Members of the Swiss HIV Cohort Study are listed at the end of the article.

Group Information: A list of the members of the Swiss HIV Cohort Study is given at the end of this article.

Arch Intern Med. 2012;172(17):1313-1321. doi:10.1001/archinternmed.2012.3216

Background Current guidelines give recommendations for preferred combination antiretroviral therapy (cART). We investigated factors influencing the choice of initial cART in clinical practice and its outcome.

Methods We analyzed treatment-naive adults with human immunodeficiency virus (HIV) infection participating in the Swiss HIV Cohort Study and starting cART from January 1, 2005, through December 31, 2009. The primary end point was the choice of the initial antiretroviral regimen. Secondary end points were virologic suppression, the increase in CD4 cell counts from baseline, and treatment modification within 12 months after starting treatment.

Results A total of 1957 patients were analyzed. Tenofovir-emtricitabine (TDF-FTC)–efavirenz was the most frequently prescribed cART (29.9%), followed by TDF-FTC-lopinavir/r (16.9%), TDF-FTC-atazanavir/r (12.9%), zidovudine-lamivudine (ZDV-3TC)–lopinavir/r (12.8%), and abacavir/lamivudine (ABC-3TC)–efavirenz (5.7%). Differences in prescription were noted among different Swiss HIV Cohort Study sites (P < .001). In multivariate analysis, compared with TDF-FTC-efavirenz, starting TDF-FTC-lopinavir/r was associated with prior AIDS (relative risk ratio, 2.78; 95% CI, 1.78-4.35), HIV-RNA greater than 100 000 copies/mL (1.53; 1.07-2.18), and CD4 greater than 350 cells/μL (1.67; 1.04-2.70); TDF-FTC-atazanavir/r with a depressive disorder (1.77; 1.04-3.01), HIV-RNA greater than 100 000 copies/mL (1.54; 1.05-2.25), and an opiate substitution program (2.76; 1.09-7.00); and ZDV-3TC-lopinavir/r with female sex (3.89; 2.39-6.31) and CD4 cell counts greater than 350 cells/μL (4.50; 2.58-7.86). At 12 months, 1715 patients (87.6%) achieved viral load less than 50 copies/mL and CD4 cell counts increased by a median (interquartile range) of 173 (89-269) cells/μL. Virologic suppression was more likely with TDF-FTC-efavirenz, and CD4 increase was higher with ZDV-3TC-lopinavir/r. No differences in outcome were observed among Swiss HIV Cohort Study sites.

Conclusions Large differences in prescription but not in outcome were observed among study sites. A trend toward individualized cART was noted suggesting that initial cART is significantly influenced by physician's preference and patient characteristics. Our study highlights the need for evidence-based data for determining the best initial regimen for different HIV-infected persons.