First-line HIV treatment outcomes following the introduction of integrase inhibitors in UK guidelines: a cohort study.

OBJECTIVE To investigate the characteristics and outcomes of people who initiated different antiretroviral therapy (ART) regimens during the era of integrase strand transfer inhibitors (INSTIs). DESIGN UK-based observational cohort study. METHODS UK Collaborative HIV Cohort study participants were included if they had started ART between 1 January 2012 and 30 June 2017. Virological failure (VF) was defined as the first of two consecutive plasma HIV RNA > 50 copies/mL, at least six months after starting ART. Follow-up was censored at ART discontinuation, class switch or death. The risk of VF among those on INSTI, protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor (NNRTI) regimens was compared using Kaplan-Meier and Cox regression methods. RESULTS Of 12,585 participants, 45.6% started a NNRTI, 29.0% a PI and 25.4% an INSTI regimen. Over a median follow-up of 20.3 months (interquartile range 7.9-389), 7.5% of participants experienced VF. Compared to those starting an NNRTI regimen, people receiving INSTIs or PIs were more likely to experience VF: INSTI group adjusted hazard ratio [aHR] 1.52, 95% confidence interval [CI] 1.19-1.95, p = 0.0009; PI group aHR 2.70, 95% CI 2.27-3.21, p < 0.0001, likelihood ratio test p < 0.0001. CONCLUSIONS First-line INSTI regimens were associated with a lower risk of VF than PI regimens but both groups were more likely to experience VF than those initiating treatment with a NNRTI. There is likely to be residual channelling bias resulting from selected use of INSTIs and PIs in specific clinical contexts, including in those with a perceived risk of poor adherence.