There are multitude of factors that go into selecting an antiretroviral treatment for your patients. From virologic efficacy of the regimen to baseline lab parameters, it’s important to consider that each patient is unique. 

DERRICK BUTLER, MD: What are the considerations that we have when we select that initial antiretroviral regimen for our patients, specifically our treatment-naïve patients? Cynthia?

CYNTHIA RIVERA, MD: So, I think of initiating antiretroviral therapy the same as I think of starting most medications. When we sit down with a patient and start a new medication, what do we want to talk about? We want to know—patients naturally want to know does this medication have side effects? If so, what are they? What other health problems do our patients have and how can those health problems potentially impact the medication that we’re starting? 

LEANDRO MENA, MD: I think as we select the regimen and make sure that we assess the patient’s readiness and also their, also, capacity, do they see themselves capable of taking this medication daily, understanding that once they start its’s going to be something they’re going to take for the rest of their lives? 

CYNTHIA RIVERA, MD: Sure, sure. 

DERRICK BUTLER, MD: Absolutely. It’s so critical, I think, because many times patients, I think, come in already with preconceptions or preconceived notions about HIV medicines. Historically, they’ve had a lot of side effects. But getting patients to understand that’s something we can work with and making that a consideration when we select a medicine for them and how we’re going to manage those. 

CYNTHIA RIVERA, MD: Empowering them with the information is big.

DERRICK BUTLER, MD: Exactly. So another area that I think we should talk about in terms of considering the antiretroviral regimen for our patients is, of course, their laboratory parameters, what is their clinical picture at the time. For instance, in my practice, we are checking their initial genotype to look for any transmitted resistance, their initial viral load, and also their other laboratory results, and those actually are extremely important in terms of selecting that first regimen. 

LEANDRO MENA, MD: Absolutely. I look at genotype. I typically wait for the genotype to start medications to make sure that the drugs that we decide to start are—the patient’s virus is succeptible to the drugs. 

CYNTHIA RIVERA, MD: Absolutely. And honestly, I individualize the start time depending on the degree of viremia. Specifically talking about the genotype, I may order the genotype and initiate therapy because of concerns of a high degree of viremia and wanting to maintain that set point, that immunologic set point, higher. And so that’s a very individual thing for me in my practice. 

LEANDRO MENA, MD: I agree. And there is great data that supports initiation of treatment as soon as possible to decrease the set point, as you mentioned. But also, with additional benefit, that by dropping the viral load as soon as possible you have the potential to avert or prevent ongoing transmission of HIV. 

DERRICK BUTLER, MD: I think the other factor we need to consider when we’re selecting our initial treatment is those other psychosocial issues, insurance issues, etc., that the patients may have, and I think that does play a role in my practice in terms of the regimen I’m going to choose for them, and it sometimes can be just as important as those clinical issues that we acknowledge when we’re selecting that regimen. 

CYNTHIA RIVERA, MD: Right. So that clinical and social and practical overlay is there when we’re taking care of patients, and HIV’s really no exception to that. 

DERRICK BUTLER, MD: I agree. I think one of the key components to any initial assessment for HIV care is a mental health assessment, because we know clearly, in any chronic disease, people who are depressed don’t do as well in general, and so people who have anxiety issues or other mental health issues don’t do as well. So that’s really, I think, another key component. 

LEANDRO MENA, MD: Patients don’t always feel that they may benefit from mental health. I think it’s our job to kind of help patients understand why we think it’s important. For example, I’m always concerned about how people may cope with their HIV diagnosis and the stigma. And how sometimes people who have to hide their medications at home because they don’t want anyone to know that they’re HIV-infected are more likely to forget to take their medications. People may not come to the follow-up appointments just because they are afraid of who could see them there.