Triple-Nucleoside Regimens versus Efavirenz

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Abstract
Gulick et al. (April 29 issue)1 show that for the initial treatment of human immunodeficiency virus type 1 (HIV-1) infection, a triple-nucleoside combination of abacavir, zidovudine, and lamivudine is inferior to an efavirenz-based regimen. Among patients in the triple-nucleoside group who had a viral load of less than 50 copies per milliliter, there was also a trend toward a shorter time to virologic rebound. The convenience of the regimen of the coformulated three nucleosides can be an important component of its efficacy,2 especially over the long term, when adherence tends to decline; the double-blind design of this study may not have captured this effect. Patients in whom undetectable viremia is achieved during treatment with these three nucleosides and patients switched to them after the induction of stable virologic suppression with more complex therapies may have different responses. A large, randomized trial and meta-analysis showed that simplification of therapy with abacavir was virologically inferior to simplification with efavirenz, but the difference was driven by those who had previously been exposed to suboptimal monotherapy or dual therapy.3,4 The question of whether patients with persistently suppressed viremia who receive this triple-nucleoside regimen should be switched to more potent regimens remains open.