Efavirenz versus boosted atazanavir-containing regimens and immunologic, virologic, and clinical outcomes: a prospective study of HIV-positive individuals

Cain, L.E.; Caniglia, E.C.; Phillips, A.; Olson, A.; Muga, R.; Pérez-Hoyos, S.; Abgrall, S.; Costagliola, D.; Rubio, R.; Jarrín, I.; Bucher, H.; Fehr, J.; van Sighem, A.; Reiss, P.; Dabis, F.ço.; Vandenhende, M.-A.; Logan, R.; Robins, J.; Sterne, J.A.C.; Justice, A.; Tate, J.; Touloumi, G.; Paparizos, V.; Esteve, A.; Casabona, J.; Seng, R.ém.; Meyer, L.; Jose, S.; Sabin, C.; Hernán, M.A.

Medicine 95(41): E5133


ISSN/ISBN: 1536-5964
PMID: 27741139
DOI: 10.1097/md.0000000000005133
Accession: 057691872

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To compare regimens consisting of either ritonavir-boosted atazanavir or efavirenz and a nucleoside reverse transcriptase inhibitor (NRTI) backbone with respect to clinical, immunologic, and virologic outcomes. Prospective studies of human immunodeficiency virus (HIV)-infected individuals in Europe and the United States included in the HIV-CAUSAL Collaboration. HIV-positive, antiretroviral therapy-naive, and acquired immune deficiency syndrome (AIDS)-free individuals were followed from the time they started an atazanavir or efavirenz regimen. We estimated an analog of the "intention-to-treat" effect for efavirenz versus atazanavir regimens on clinical, immunologic, and virologic outcomes with adjustment via inverse probability weighting for time-varying covariates. A total of 4301 individuals started an atazanavir regimen (83 deaths, 157 AIDS-defining illnesses or deaths) and 18,786 individuals started an efavirenz regimen (389 deaths, 825 AIDS-defining illnesses or deaths). During a median follow-up of 31 months, the hazard ratios (95% confidence intervals) were 0.98 (0.77, 1.24) for death and 1.09 (0.91, 1.30) for AIDS-defining illness or death comparing efavirenz with atazanavir regimens. The 5-year survival difference was 0.1% (95% confidence interval: -0.7%, 0.8%) and the AIDS-free survival difference was -0.3% (-1.2%, 0.6%). After 12 months, the mean change in CD4 cell count was 20.8 (95% confidence interval: 13.9, 27.8) cells/mm lower and the risk of virologic failure was 20% (14%, 26%) lower in the efavirenz regimens. Our estimates are consistent with a smaller 12-month increase in CD4 cell count, and a smaller risk of virologic failure at 12 months for efavirenz compared with atazanavir regimens. No overall differences could be detected with respect to 5-year survival or AIDS-free survival.