Letter to the editor
Optimizing antiretroviral
therapy for HIV infection: new tendency
Optimización del tratamiento antirretroviral para el VIH: nueva tendencia
José Antonio Lamotte
Castillo1* https://orcid.org/0000-0002-4558-2070Â
1Centro
Provincial de Higiene, EpidemiologÃa y MicrobiologÃa. Santiago de Cuba, Cuba.
*Autor para correspondencia. Correo electrónico: joseantonio.lamotte@nauta.cu
Recibido: 20/12/2021
Aprobado: 05/01/2022
To the editor
Despite of coronavirus
pandemic with its serious consequences for the world-wide health and the
economy in a short time (months), the HIV infection remains by years as a
complicated health problem for the world too. But with the great difference the
last entity has some successful therapeutics, although there is no cure, a very
good control of the infection can be achieved. It is very important to take
into account that nowadays all patients should start antiretroviral regimen, no
matter his clinical or immunological stage, the tendency is diagnosis and treatment,
as early as possible, to avoid the damage to the immunological system by the
HIV virus. The goals of this therapy continue being: Â to get the maximum control of viral replication
and to restore the immunodeficiency, so as to prevent the opportunist
infections.(1)
The antiretroviral drugs
have undergone a dramatic development and had passed the three principals
problems of them, which consist of the potency antiviral effect, the toxicity
and the burden pills. The majority of the first drugs approved at the beginning
of the epidemic, are not recommended for use today. New combinations with more
potency antiviral effect, minor toxicity and fewer burden pills have arised.
Up to now, the regimen recommended
to treat this infection was the combination of at least three or more drugs, working
in different parts of the viral replication cycle, it was called highly active antiretroviral
treatment or megatherapy respectively.(2)
First, the non - nucleoside reverse transcriptase inhibitor was the corner stone
of these regimens, in combination with the nucleoside∕nucleotide reverse
transcriptase inhibitor. Â After, the
protease inhibitors  was
the group which helped the most those patients with serious immunological
problems and highly viral load, but the toxicity has been their principal
limitation prescription. Other drugs were developed (as fusion inhibitor) with the
hope of improving the antiretroviral effect, but the fact was not really like
that. In the case of the CCR5 antagonist, its antiviral depends on specific
host receptor characteristics.(1-3)
Finally, a new group has
been developing, the integrase strand transfer inhibitors, which have changed the
traditional point of view in this topic; principally the Dolutegravir, which
has high antiviral effect, less toxicities, high resistance barrier and a very
important aspect: fewer burden pills. Thanks to these characteristics of the
new drug, the compulsory use of three antiretroviral drugs has changed into two
only drugs, thereby reducing the number of pills. (4)
However, it is important
that patients have adequate control of viral replication, characterized by non-detectable
level of viral load. This new option is called optimizing antiretroviral
therapy in the setting of viral suppression. This alternative has improved the adherence
to antiretroviral regimen, by reducing the hospital admission for any
opportunistic infection and the most important; the mortality rate for aids. (3-5)
The fundamental principle
of regimen optimization is to maintain viral suppression without jeopardizing
the future treatment options.
Only Dolutegravir with Lamivudine
and Lopinavir∕Ritonavir together with Lamivudine can be prescribed with this
aim. (4,5)
"Reasons
to consider regimen optimization in the setting of viral suppression"
-
To simplify a regimen by reducing pill burden or
dosing frequency
-
To enhance tolerability and or decrease short- or
long-term toxicity
-
To prevent or mitigate drug-drug interactions
-
To eliminate food or fluid requirements
-
To reduce costs(4)
Remember these regimens cannot
be prescribed to patients with titers of viral load ˃1000 cp ∕mL; patients with
coinfection such as hepatitis B or C virus.
Owing to the presence of comorbidities
in these patients, this option will be another alternative to reduce drugs
interaction and toxicity, and better adherence.
Before changing the patient
to any optimizing regimen, recent viral load must be done,
even HIV drugs resistance studies if viral suppression has fail at any time of
the clinical course of the patient. After the change, monitoring of viral load should
be frequently prescribed, according to the national protocol recommendations. 2
This new tendency of the antiretroviral
should be known by family doctors in primary care, and by HIV care provider
either in primary care and secondary care.
As health team gets
protocols of treatment less complicated to the patients, it will be easier to achieve
better adherence to this treatment, and there after the strategy 90-90-90 in
this year can be possible.Â
Referencias bibliográficas
1. Roca Goderich. Temas de
Medicina Interna. Tomo llI. 5 ed. La Habana: Editorial Ciencias Médicas, 2017. [citado
17/10/2021]. Disponible en: http://www.bvs.sld.cu/libros_texto/roca_temas_medicina_interna_tomo3_quintaedicion/medicina_internaiii_completo.pdf
2. Lantero Abreu MI, Sánchez Fuentes
J, Joanes Fiol J, Betancourt Llody YA, Cancio Enrique I, Matos
Morejón MJ, et al. Plan estratégico nacional para la prevención y control de
las ITS, el VIH y las hepatitis 2019- 2023. La Habana: Ministerio de
Salud Pública, 2019. p. 131-170.
3. Panel on Antiretroviral Guidelines
for Adults and Adolescents. Guidelines for the use of antiretroviral
agents in adults and adolescents with HIV. Department
of Health and Human Services. [citado 26/08/2021]: I -22. Â Aviable
at: https://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf
  Â
4. Snedecor SJ, Radford M,
Kratochvil D, Grove R, Punekar YS. Comparative efficacy and
safety of dolutegravir relative to common core agents in treatment-naïve
patients infected with HIV-1: a systematic review and network meta-analysis. BMC Infect Dis. 2019 [citado
26/08/2021]; 19(484). Disponible en: https://doi.org/10.1186/s12879-019-3975-6
5. España. GESIDA, Ministerio de sanidad consumo y bienestar
social. Documento de consenso de GeSIDA ∕Plan nacional sobre el sida respecto
al tratamiento antirretroviral en adultos infectados por el virus de la
inmunodeficiencia humana. (Actualización enero 2019), [citado 17/10/2021]. Disponible en: https://gesida-seimc.org/wp-content/uploads/2019/01/gesida_DC_TAR_2019_v_final.pdf
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