Dr. Gallant is the medical director of specialty services at Southwest CARE Center.
The standard of care for initial therapy is still a combination of two nucleoside analogs ("nukes") plus a third agent. We haven't been able to get away from that approach for the last 20 years. But after multiple unsuccessful experiments with one- or two-drug regimens and "nuke-sparing" regimens, we may finally be getting closer.
For example, the combination of cabotegravir and rilpivirine [Edurant], both of which can be given as long-acting injections, looks promising in the LATTE-2 study. Even more impressive are the very preliminary data on dolutegravir [Tivicay, DTG] plus lamivudine [3TC, Epivir], which did well in a small 20-person study. It's too early to say whether this will be a game-changer because it may not work in larger trials. But if it does -- if this simple, well-tolerated two-drug regimen is as effective as standard-of-care regimens, with no resistance -- it will be hard to think of a reason not to use it.
Ironically, this comes at a time when our nukes are getting safer. Tenofovir alafenamide [TAF] appears to have all the advantages of tenofovir disoproxil fumarate [TDF] without the disadvantages of kidney and bone toxicity, so there's less motivation now to avoid nukes from a toxicity standpoint. But would no tenofovir be better than new-and-improved tenofovir? We'll have to wait and see.
Credit: MedPage Today via Joel Gallant.