Non-nucleoside reverse transcriptase inhibitor- versus ritonavir-boosted protease inhibitor-based regimens for initial treatment of HIV infection: a systematic review and meta-analysis of randomised trials.
BACKGROUND:
Previous studies suggest that non-nucleoside-reverse-transcriptase inhibitors (NNRTI) cause faster virologic suppression while ritonavir-boosted-protease inhibitors (PI/r) recover more CD4 cells. However, individual trials have not been powered to compare clinical outcomes.
METHODS:
We searched databases (up to February 2016) to identify randomised trials comparing NNRTI- vs PI/r-based initial therapy. A meta-analysis calculated risk ratios (RRs) or mean differences (MDs), as appropriate. Primary outcome was death or progression to AIDS. Secondary outcomes were: death, progression to AIDS and treatment discontinuation. We calculated RR of virologic suppression and MD for increase of CD4 cells at week 48.
RESULTS:
We included 29 trials with 9047 participants. In intention-to-treat analyses, death or progression to AIDS occurred in 226 participants in the NNRTI arm and 221 in the PI/r arm (RR: 1.03 [95%CI: 0.87-1.22], 12 trials; n=3825), death in 205 participants in the NNRTI arm vs 198 in the PI/r arm (1.04 [0.86-1.25]; 22 trials; n=8311) and progression to AIDS in 140 participants in the NNRTI arm vs 144 in the PI/r arm (1.00 [0.80-1.25]; 13 trials; n=4740) Overall treatment discontinuation (1.12 [0.93-1.35], 24 trials, n=8249) and from toxicity (1.21 [0.87-1.68], 21 trials; n=6195) were comparable, but discontinuation due to virologic failure was more common with NNRTI (1.58 [0.91-2.74], 17 trials; n=5371). At week 48, there was no difference between NNRTI and PI/r in virologic suppression (RR: 1.03 [0.98-1.09]) or CD4+recovery (MD: -4.7 cells [-14.2 to 4.8]) CONCLUSIONS: In this comprehensive meta-analysis, we found no difference in clinical and viro-immunologic outcomes between NNRTI- and PI/r-based therapy.