The best antiretroviral drug on the market is…

I am sure you would like to know the answer to this question. But it isn’t a simple one to answer…it depends on a whole variety of factors from patient’s schedule, adherence history, other medications, cost and side effects but before going in to details, let me backtrack a bit and discuss anti-retroviral drugs in general.

There are more than 20 approved antiretroviral drugs belonging to four different groups. Combination therapy is taking two or more anti-retroviral drugs at a time, whilst High Active Antiretroviral Therapy (HAART) is more commonly referred to when taking a combination of three or more ARVs.

Two or more ARVs —combination or HAART or drug cocktails —must be taken otherwise HIV will become resistant to the drugs quickly and stop working. Combining drugs prolongs effective treatment.

The four groups of ARVs have long scientific names based on how they fight HIV as well as their chemical structure, in short they are NRTIs/NtRTIs, NNRTIs, PIs and integrase inhibitors. Most common drug combinations have two NRTIs combined with an NNRTI or a “boosted” protease inhibitor (PI).

Fixed dose combinations combine two or more drugs in a single pill such as Atripla which is the current World Health Organisation recommended treatment. Atripla is a once-a-day  pill containing three drugs — tenofovir (NtRTI), efavirenz (NNRTI)and or emtricitabine (NRTIs). The combination of drugs given to persons with HIV when they start treatment is referred to as first line treatment. If a person experiences terrible side effects or develops resistance to the first line treatment then they are provided second line therapy.

Some combinations of ARVs are more effective than others. In 2012, researchers at Johns Hopkins University in the USA used mathematical formulas to determine which combinations worked best out of 857 different combinations of anti-retrovirals.  However, the best option for one person might not be good for another person.  The choice of drugs depends on a number of factors: side effects, cost of the medication, whether patient has access to laboratory tests like viral load, the number of pills that have to be taken and more.

Stribild (previously known as Quad) as it contains four ARVs is believed to be the most effective treatment. It combines elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate. Stribild is believed to more effective than Atripla, one study found 88 percent of persons on Stribild had undetectable viral loads compared to 84 percent on Atripla. Stribild also has fewer side effects than Atripla.

Stribild is very pricey. It is produced by the same company, Gilead, that makes Atripla. Stribild initial price was $28 500 per person per year but the manufacturers have negotiated deals to lower the costs. But even with these negotiated costs it will be out of reach for most Malawians. The new regimen which is being phased in Malawi a pill a day of tenofovir, efavirenz and lamivudine is comparably effective and more affordable. The search for better treatments, vaccines and a cure continues.