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Practice Therapeutics

Two-drug antiretroviral regimens for HIV

BMJ 2023; 382 doi: https://doi.org/10.1136/bmj-2022-071079 (Published 01 September 2023) Cite this as: BMJ 2023;382:e071079
  1. John P Thornhill, clinical senior lecturer, honorary consultant physician12,
  2. Ben Cromarty, UK-CAB representative3,
  3. Jessica Gaddie, specialist registrar2,
  4. Shiellah Mushunje, UK-CAB representative3,
  5. Rashida A Ferrand, professor of international health45
  1. 1Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, UK
  2. 2Barts Health NHS Trust, London, UK
  3. 3UK Community Advisory Board (UK-CAB), HIV treatment advocates network
  4. 4Clinical Research Department, London School of Hygiene and Tropical Medicine, UK
  5. 5Biomedical Research and Training Institute, Harare, Zimbabwe
  1. Correspondence to: J P Thornhill j.thornhill{at}qmul.ac.uk

What you need to know

  • Antiretroviral therapy regimens containing two active drugs rather than the traditional three or more are efficacious in treating HIV

  • Two-drug regimens are a particularly useful option when tenofovir alafenamide, tenofovir disoproxil fumarate, or abacavir cannot be used or are not optimal—for example, for people with high cardiovascular risk, renal impairment, or decreased bone mineral density

  • Many two-drug regimens can be used by people who are electively switching HIV treatment and have an undetectable viral load, and one regimen is licensed for people newly starting antiretroviral therapy

  • They are not suitable for people with HIV and hepatitis B co-infection, or in those with a history of HIV drug resistance or during pregnancy

  • One long acting injectable two-drug regimen is also available, but this may not be suitable in those with a high body mass index, certain viral subtypes, or with HIV drug resistance

A 59 year old man who has been living with HIV for 15 years has been taking tenofovir disoproxil fumarate/emtricitabine and dolutegravir once daily for 10 years, and has an undetectable HIV viral load. He smokes 10 cigarettes a day and has a body mass index (BMI) of 29. His risk of developing a heart attack or stroke over the next 10 years as calculated by the QRISK3 algorithm is 14%. He recently developed renal tubular dysfunction attributed to tenofovir use. Until recently, the standard options in HIV treatment guidelines included two non-nucleos(t)ide reverse transcriptase inhibitors. Tenofovir disoproxil fumarate would be inappropriate due to the presence of renal tubular dysfunction, and abacavir would be because of a high risk of cardiovascular event. What other HIV treatment options are available for this man?

What is a two-drug ART regimen for adults living with HIV?

HIV treatment or antiretroviral therapy (ART) has traditionally consisted of three active drugs (table 1). Where individuals have continued access to HIV care, ART has allowed …

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