Dual therapy with ritonavir-boosted protease inhibitor (PI) plus lamivudine versus triple therapy with ritonavir-boosted PI plus two nucleos(t)ide reverse-transcriptase inhibitor in HIV-infected patients with viral suppression

Predicted environmental concentration (PEC), environmental risk assessment (ERA) and prioritization of antiretroviral drugs (ARVs) in seawater from Guarujá (Brazilian coastal zone)

The antiretroviral therapy program's success in managing the human immunodeficiency virus (HIV) has inadvertently led to the release of antiretrovirals (ARVs) into worldwide aquatic ecosystems. However, few studies investigated the risks of ARV loadings that flow continuously to the marine waters of South America (such as Brazil). Against this backdrop, the aims of this study were: (i) to estimate the Predicted Environmental Concentration (PEC) of thirteen ARVs worldwide used in HIV treatment, and which are frequently disposed of in the marine aquatic ecosystems of Guarujá, São Paulo coastline, Brazil.; (ii) predict, through the Environmental Risk Assessment (ERA), the potential acute and chronic risks of these ARVs; and (iii) create a prioritization list of the most hazardous ARVs, based on the intrinsic properties of these compounds, i.e.: occurrence (O); persistence (P), bioaccumulation (B) and toxicity (T) (OPBT criteria). The PEC calculations indicated that all the ARVs examined in this study require an assessment of their impact on aquatic organisms, as all results exceeded the limits set by the guidelines of the European Medicines Agency., i.e., the PEC ranged between 0.37 and 99.39 μg/L. The results of individual ERA showed the following trend: (i) 56.41% of the results of acute toxicity indicated high toxicity for the three trophic levels; 33.33% of the results indicated low risk for one of the trophic levels, and 10.26% indicated moderate toxicity, and (ii) in terms of chronic toxicity, 33.33% of the results indicated moderate risks, 35.90% indicated low or no risk, and 30.77% indicated high risks. Regarding the results of the mixture of ARVs, the ERA showed a high acute and/or chronic risk for all five classes tested, i.e., (i) nucleoside/nucleotide reverse transcriptase inhibitors; ii) non-nucleoside reverse transcriptase inhibitors; iii) protease inhibitors; (iv) integrase strand transfer inhibitors; and (v) chemokine receptor antagonists. Ultimately, the final ranking of the OPBT approach was etravirine (the highest-priority ARV in seawater from Guarujá), followed by: nevirapine > efavirenz > ritonavir > lopinavir > maraviroc > atazanavir > darunavir > abacavir > dolutegravir > zidovudine > tenofovir > lamivudine.

Risk of viral failure after simplification therapy without using integrase inhibitors compared with maintenance of triple antiretroviral therapy: A systematic review and meta-analysis

BACKGROUND

Antiretroviral drug simplification is a strategy to reduce drug exposure and improve treatment adherence. Nowadays, dolutegravir plus lamivudine is the most preferred regimen, which might lead in the future with problems related to drug resistance or drug intolerance. This meta-analysis aimed to assess the safety of HAART simplification without integrase inhibitors.

METHODS

We conducted a systematic review and meta-analysis using the Embase and Medline databases to include clinical trials and observational studies published between 2008 and March 2024. The studies focused on HIV-positive individuals with suppressed viral load who either simplified their treatment to dual therapy without integrase inhibitors or continued triple therapy. The primary outcome of interest was the likelihood of viral failure within 48 weeks.

RESULTS

Ten studies were included, with a total of 1,977 patients. Boosted Protease Inhibitors (PI) were the core of antiretroviral simplification therapy. The simplification group did not show an increased risk of virological failure, with a pooled RR in 48 weeks of 1.29 (0.61‒2.73, I² = 51 %) when compared to control group. Boosted protease inhibitors were preferred combined with lamivudine, nevirapine, efavirenz, and maraviroc). Only maraviroc plus boosted PI combination was associated with a higher risk of virological failure with an RR of 4.49 (1.99‒10.11).

CONCLUSION

Simplification therapy with boosted PI plus lamivudine or non-nucleoside transcriptase reverse inhibitors was a safe strategy and not associated with a higher risk of virological failure. This approach might be an alternative to dolutegravir-based simplification regimens if needed.

Two-Drug Regimens for HIV-Current Evidence, Research Gaps and Future Challenges

During the last 30 years, antiretroviral treatment (ART) for human immunodeficiency virus (HIV) infection has been continuously evolving. Since 1996, three-drug regimens (3DR) have been standard-of-care for HIV treatment and are based on a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs). The effectiveness of first-generation 3DRs allowed a dramatic increase in the life expectancy of HIV-infected patients, although it was associated with several side effects and ART-related toxicities. The development of novel two-drug regimens (2DRs) started in the mid-2000s in order to minimize side effects, reduce drug-drug interactions and improve treatment compliance. Several clinical trials compared 2DRs and 3DRs in treatment-naïve and treatment-experienced patients and showed the non-inferiority of 2DRs in terms of efficacy, which led to 2DRs being used as first-line treatment in several clinical scenarios, according to HIV clinical guidelines. In this review, we summarize the current evidence, research gaps and future prospects of 2DRs.

Impact of Medication Regimen Simplification on Medication Adherence and Clinical Outcomes in Patients with Long-Term Medical Conditions

BACKGROUND

This study aims to identify interventions used to reduce medication regimen complexity and to assess their impact on medication adherence and clinical outcomes.

METHODS

A literature search was conducted using pre-defined search terms in three scientific databases, including ScienceDirect, ProQuest and MEDLINE. Original research articles published in English between 2009 and 2020 that assessed the impact of medication regimen simplification on medication adherence in patients with long-term medical conditions were eligible for inclusion. Review articles, meta-analysis studies and conference proceedings were excluded. Data charting was done in an iterative process using a study-specific extraction form.

RESULTS

Of the 684 studies identified through initial searches, 17 studies were included in the review. Nine studies involved simplification of medication regimen related to HIV, while three studies focused on patients with diabetes with or without coronary artery disease. The remaining five studies included medications used among elderly patients or medications related to hypertension, psychiatric disorders, glaucoma and kidney diseases. Three medication regimen simplification strategies were identified; fixed-dose combination (n = 7), once-daily dosing (n = 4) and the combination of both fixed-dose and once-daily dosing (n = 6). Overall, most of the regimen simplification strategies (14 out of 17) were found to be useful in improving medication adherence. There was no assessment of clinical outcomes in four out of 17 studies. Furthermore, more than half of the studies that assessed clinical outcomes did not show any additional impact on clinical outcomes.

CONCLUSION

The findings suggest that there was an equal utilization of the three main approaches of regimen simplifications; fixed-dose combination, once-daily dosing and a combination of both. Overall, most of the regimen simplification strategies were found to be effective in improving medication adherence. However, the associated improvement in medication adherence did not extend to improvement in the clinical outcomes.