Advanced HIV Infection in Treatment-Naïve Individuals: Effectiveness and Persistence of Recommended 3-Drug Regimens

Abstract

Background: Approximately 20% of newly diagnosed people with HIV (PWH) in the United States have advanced HIV infection, yet the literature on current antiretroviral therapy (ART) options is limited. The discontinuation/modification and effectiveness of common regimens were compared among ART-naïve people with advanced HIV infection (CD4 cell count <200 cells/μL).

Methods: ART-naïve adults with advanced HIV infection initiating bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) or a boosted darunavir (bDRV)-, dolutegravir (DTG)-, or elvitegravir/cobicistat (EVG/c)-based 3-drug regimen between January 1, 2018, and July 31, 2019, in the OPERA cohort were included. The association between regimen and discontinuation or viral suppression (<50 or <200 copies/mL) was assessed using Cox proportional hazards models with inverse probability of treatment weights.

Results: Overall, 961 PWH were included (416 B/F/TAF, 106 bDRV, 271 DTG, 168 EVG/c); 70% achieved a CD4 cell count ≥200 cells/μL over a 16-month median follow-up. All regimens were associated with a statistically higher likelihood of discontinuation than B/F/TAF (bDRV: adjusted hazard ratio [aHR], 2.65; 95% CI, 1.75-4.02; DTG: aHR, 2.42; 95% CI, 1.75-3.35; EVG/c: aHR, 3.52; 95% CI, 2.44-5.07). Compared with B/F/TAF, bDRV initiators were statistically less likely to suppress to <50 copies/mL (aHR, 0.72; 95% CI, 0.52-0.99) and <200 copies/mL (aHR, 0.55; 95% CI, 0.43-0.70); no statistically significant difference was detected with DTG or EVG/c.

Conclusions: Among people with advanced HIV infection, those initiating B/F/TAF were less likely to discontinue/modify their regimen than those on any other regimen, and more likely to achieve viral suppression compared with those on bDRV but not compared with those on other integrase inhibitors.

Keywords: advanced HIV; antiretroviral therapy; cohort; discontinuation; effectiveness; late presenters.

Figure 1.

Adjusted^a association between regimen and regimen discontinuation. ^aEstimated with a Cox proportional hazards model with stabilized inverse probability of treatment weights, controlling for baseline sex, Black race, hepatitis B, index year, age, CD4 cell count, and viral load. Abbreviations: B/F/TAF, bictegravir/emtricitabine/tenofovir alafenamide; bDRV, boosted darunavir; DTG, dolutegravir; EVG/c, elvitegravir/cobicistat; HR, hazard ratio.

Figure 2.

Adjusted^a association between regimen and viral suppression. ^aEstimated with a Cox proportional hazards model with stabilized inverse probability of treatment weights, controlling for baseline sex, Black race, hepatitis B, index year, age, CD4 cell count, and viral load. Abbreviations: B/F/TAF, bictegravir/emtricitabine/tenofovir alafenamide; bDRV, boosted darunavir; DTG, dolutegravir; EVG/c, elvitegravir/cobicistat; HR, hazard ratio; VL, viral load.

Figure 3.

Cumulative probability of achieving a CD4 cell count ≥200 cells/μL. Abbreviations: B/F/TAF, bictegravir/emtricitabine/tenofovir alafenamide; bDRV, boosted darunavir; DTG, dolutegravir; EVG/c, elvitegravir/cobicistat.