Success and failure of initial antiretroviral therapy in adults

Abstract

We updated a prior systematic review of initial ART efficacy through Week 144. Studies (1994-July 2017) were drawn from PubMed, ClinicalTrials.gov, Cochrane Library, and major conferences; design, eligibility, subject and ART data were abstracted. Outcomes are expressed as group size-weighted means. Mixed-effects meta-regression was used to identify sources of efficacy heterogeneity. Within 354 groups (181 studies, 77,999 subjects), principal backbones were tenofovir-emtricitabine (TDF/TAF-FTC) (44.2%), thymidine-based (27.7%), and abacavir-lamivudine (9.7%). Principal anchors were non-nucleoside analogue (49.7%), boosted protease inhibitor (28.1%) and integrase inhibitor (INSTI; 11.5%). Mean intention-to-treat efficacy (RNA20% of post-2010 subjects failed over 3 years. Real-world efficacy is lower than in phase-3 trials. Guidelines should list non-INSTI-based initial ART as non-preferred. Strategies are needed to improve access to pre-ART genotyping and to increase early initiation of once-daily ART.