Lopinavir/Ritonavir

Initial vs Subsequent Therapy

Adult and adolescent treatment guidelines of the U.S. Department of Health and Human Services state that lopinavir/ritonavir given twice daily in combination with 2 nucleoside analogues is "not recommended" for initial antiretroviral therapy. However, the guidelines list the combination of lopinavir/ritonavir (given twice daily) + lamivudine as an initial "regimen to consider" when abacavir, tenofovir alafenamide, and tenofovir disoproxil fumarate cannot be used.
        
        Regimens containing lopinavir/ritonavir have been shown to achieve effective viral suppression in initial and subsequent therapy.
        
        Lopinavir/ritonavir, used with stavudine and lamivudine as initial treatment, was significantly more effective in achieving virologic suppression than the combination of nelfinavir + stavudine + lamivudine (HIV RNA <50 copies/mL in 67% vs 52% at 48 weeks; p < .001).(1)
        
        In a study comparing lopinavir/ritonavir with ritonavir-boosted fosamprenavir, the 2 boosted protease inhibitors, given in combination with abacavir + lamivudine, provided comparable rates of virologic suppression and similar increases in CD4 cell counts. At 48 weeks, by intent-to-treat analysis, the proportion of subjects with HIV RNA <50 copies/mL was 65% in the lopinavir/ritonavir group and 66% in the fosamprenavir + ritonavir group. CD4 count increases were 191 cells/µL and 176 cells/µL, respectively.(3)
        
        In a randomized comparison between lopinavir/ritonavir and efavirenz, each given with 2 nucleoside analogues, lopinavir/ritonavir recipients had lower rates of virologic suppression to <50 copies/mL at 48 weeks (77% for lopinavir/ritonavir and 89% for efavirenz recipients; p = .003), though greater increases in CD4 cell counts (285 and 241 cells/µL, respectively; p = .01). A third treatment group was given efavirenz + lopinavir/ritonavir, without nucleoside analogues; 83% of subjects in this group had virologic suppression to <50 copies/mL.(4)
        
        Following failure of initial treatment with 2 nucleoside analogues and a protease inhibitor other than lopinavir/ritonavir, a majority of patients with no prior NNRTI use experienced suppression of viral load for 48 weeks after switching to a regimen containing lopinavir/ritonavir, nevirapine, and 1 new nucleoside analogue.(5)
        
In a study of individuals with extensive nucleoside analogue and protease inhibitor experience (but no prior NNRTI experience) and virologic recurrence on treatment, changing to a regimen including lopinavir/ritonavir and efavirenz resulted in viral load suppression at week 24 in the majority of participants.(6)