The Specialist Forum Volume 13 No 11 November 2013 | Page 14

HIV/AIDS

be costly, particularly where issues of adherence and retention in care
have not been adequately sorted.

Future fixed-dose combination options
Atripla and its generics are first-line ARVs. Patients who are ART naïve
are being prioritised. Atripla, odimune, tribuss and atroiza all contain EFV
and TDF. Drug toxicity is still an issue and non-adherence will still lead to
resistance. Intolerance to EFV means intolerance to the fixed-dose formulation too. Approximately 4%-8% of patients on EFV develop rashes.
A smaller number experience depression, psychosis and suicidal
thoughts. Similarly, TDF brings safety concerns: bone demineralisation
and renal impairment (1%-2%). The incidence of TDF-induced renal injury
in SA seems to be low (Brennan A et al). Nevertheless, its consequences
are devastating and can include the death of the patient. Dialysis is not
easily accessed in rural Africa. Bone demineralisation is difficult to diagnose and easy to miss.
Alternative FDCs are then needed. Stribild (TDF+FTC+CBS+EGV) and
complera (TDF+FTC+RPV) are registered for use in the US and Europe.
Both can be used as first-line and second-line ART where appropriate.
Stribild contains cobicistat+elvitegravir (EGV) and an NRTI backbone
consisting of (TDF+FTC). EGV is an integrase strand-transfer inhibitor (ISTI).
Cobicistat is a pharmacokinetic (PK) enhancer (it increases blood and tissue drug levels). In clinical trials, the efficacy of stribild at 96 weeks has been
similar to that of atripla, but with less skin rash, less neuropsychiatric disturbance and less elevation of LDL-cholesterol (Zolopa et al). It’s an FDC without the toxicity of EFV, yet with ??????????????%???????????????Q)??????Q???????????????????????????????????????????????????)??????????????????M???????????????????????????
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