We have efficacious first-line drugs now and better drugs becoming available, which have the potential for improved tolerability and reduced cost. While a single Efavirenz (EFV)-based fixed dose combination for almost everybody with HIV has been a remarkable public health achievement, it needs to be rethought based on the data that we currently available.
The concept of a limited formulary of first-line drugs with two choices, either DTG or EFV (at whatever dose is finally decided), paired with TDF and either FTC or 3TC is supported. TDF and TAF are considered interchangeable for this formulary exercise. The limited formulary is thought to be programmatically feasible even as we move to more decentralization and task shifting. A simple algorithm could guide providers in the choice of regimen.
The appropriateness of switching from EFV to DTG is necessary. The scale down of stavudine (d4T) was driven by side effects and any possible scale down of EFV does not have the same level of urgency, as millions of people around the world are stable on an EFV-containing regimen. How to potentially switch people from EFV to DTG is therefore an open question.
A possible scenario is that all those who are stable on the EFV could remain on that regimen, those with tolerability issues be switched and those initiating antiretroviral therapy (ART) for the first time could start the DTG (especially those with high CD4 counts and no HIV-related symptoms) who may benefit from the benefit from the better tolerability of DTG.
In terms of first-line drug optimization, there are three bodies of work around DTG, EFV 400 mg and TAF. Studies are ongoing to examine the efficacy and tolerability of DTG in access markets with a particular focus on its use in pregnancy and HIV/TB coinfection.
It was predicted that the cost of DTG would be the same or less than currently available regimens. A study is ongoing to examine the use of EFV 400 mg in pregnancy and funding is needed to study it in HIV/TB coinfection.
The group decided it would be important to discuss further with Gilead its development plans for TAF in both the commercial and access markets. Boosted versus unboosted TAF, access to PK/PD data and use of TAF in pregnancy and people with HIV/TB co-infection were highlighted by the group as issues relevant to resource limited settings.
WHAT KIND OF ART DO YOU WISH TO HAVE IN KENYA BY 2017?
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