Abstract
While the introduction of combination highly active antiretroviral therapy (HAART) regimens represents an important advance in the management of human immunodeficiency virus (HIV)-infected patients, tolerability can be an issue and the use of several different agents may produce problems. The switch of combination HAART to ritonavir-boosted protease inhibitor (PI) monotherapy may offer the opportunity to maintain antiviral efficacy while reducing treatment complexity and the risks of toxicity. Current European AIDS Clinical Society (EACS) guidelines recognise ritonavir-boosted PI monotherapy with twice-daily lopinavir/ritonavir or once-daily darunavir/ritonavir as a possible option in patients who have intolerance to nucleoside reverse transcriptase inhibitors, or for treatment simplification. Clinical trials data for PI boosted monotherapy are encouraging, showing substantial efficacy in the majority of patients; however, further data are required before this approach can be recommended as a routine treatment. Available data indicate that the most suitable candidates for the use of boosted PI monotherapy are long-term virologically suppressed patients who have demonstrated good adherence to antiretroviral therapy, who do not have chronic hepatitis B, have no history of treatment failure on PIs and are able to tolerate low-dose ritonavir.
Highlights
While the introduction of highly active antiretroviral therapy (HAART), typically involving three drugs in combination, has been an important advance in the treatment of people infected with human immunodeficiency type-1 virus (HIV-1), many patients do not remain on their original treatment regimen one year after starting HAART (EuroSIDA study; Figure 1) [1]
The available evidence indicates that, in a large proportion of patients, effective long-term virological control is possible with boosted protease inhibitor (PI) monotherapy and if re-suppression is needed this can be achieved with the re-introduction of nucleoside reverse transcriptase inhibitor (NRTI)
The current European AIDS Clinical Society (EACS) guidelines define potentially central nervous system (CNS)-active drugs as antiretrovirals with either demonstrated clear cerebrospinal fluid (CSF) penetration when studied in HIVinfected populations (CSF concentration above the 90% inhibitory concentration [IC90] in > 90% of examined patients), or with proven short-term (3–6 months) efficacy with respect to cognitive function or CSF viral load decay when evaluated as single agents or in controlled studies in peer reviewed papers
Summary
While the introduction of highly active antiretroviral therapy (HAART), typically involving three drugs in combination, has been an important advance in the treatment of people infected with human immunodeficiency type-1 virus (HIV-1), many patients do not remain on their original treatment regimen one year after starting HAART (EuroSIDA study; Figure 1) [1]. Available data show only a small difference in efficacy between triple-drug HAART and boosted PI monotherapy following treatment switch (Figure 2a [lopinavir/r] and 2b [darunavir/r]) and in the MONET study with darunavir/r monotherapy, effective viral suppression was maintained up to three years of treatment [20].
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