SPOTLIGHT: The evolution of HIV treatment: From multi-pill regimens to better, single-pill combos

HIV treatment has been improved and simplified significantly over the years, yet a small fraction of people living with HIV still take complex multi-pill regimens. Spotlight reports on a new combination pill that could make life easier for some in this group. But as two leading experts point out, the development comes as traditional categorisation of HIV medicines is dissolving.

Twenty years ago, antiretroviral treatment involved taking a number of pills, sometimes many times a day. Though these medicines saved many lives, they did cause a variety of side-effects, and many people developed resistance to some of the drugs.

Since then we’ve seen significant scientific advances. The drugs that cause notable side-effects have largely been phased out. In 2013, the government introduced a one pill, once a day regimen as the standard first-line treatment.

In 2019, first-line treatment was further strengthened when a breakthrough new antiretroviral drug called dolutegravir was included in a new daily combination pill. Apart from high potency and having very few side-effects, the new combination is also remarkably robust against the development of drug resistance.

Dolutegravir made it possible for many people who were on second-line regimens to switch away from multiple tablets to a single tablet containing the drug, Professor Francois Venter tells Spotlight. Venter is a clinician researcher with Ezintsha at the University of the Witwatersrand.

This regimen, a combination of the drugs tenofovir disoproxil fumarate, lamivudine and dolutegravir (TLD), is still the backbone of South Africa’s HIV treatment programme, with more than five million people taking it every day. It is also recommended by the World Health Organization for treatment of almost all people living with HIV.

There is, however, a subset of people living with HIV for whom TLD doesn’t work and who accordingly may need more complex treatment regimens. Such regimens have typically required taking a number of pills, many times a day, but new research suggests that might not be the case for much longer.

A phase three study, called ARTISTRY 1, published in the Lancet medical journal in February, looked at the safety and efficacy of a combination pill containing the drugs bictegravir and lenacapavir compared with several more complex HIV regimens. There were nine different complex regimens being taken by participants in the study. The bictegravir and lenacapavir pill was found to be non-inferior (meaning roughly as good as) to the complex regimens, and no drug resistance was seen. People in the stud