Protease inhibitor-based antiretroviral therapy in treatment-naive HIV-1-infected patients: the evidence behind the options

The introduction of protease inhibitors (PIs) to HIV treatment combinations in 1996 has significantly reduced morbidity and mortality due to HIV infection. Since the 1990s, multiple PIs have been approved, with several boosted PI regimens recognized as first-line regimens in antiretroviral therapy (ART)-naive patients. While the current guidelines recommend non-nucleoside reverse transcriptase inhibitor-, PI- and integrase inhibitor-based regimens as equal alternatives in ART-naive patients, there are clearly selected patients for whom PI-based regimens appear to be the best option because of specific toxicity or dosing issues. Due to the multiple options of therapy available for ART-naive patients, providers initiating PI-based ART can individualize therapy based on patient characteristics and needs, including pre-treatment resistance, drug-drug interactions, adverse effect profiles and co-morbid conditions. Here, we discuss the current recommendations and recent guidelines, and the evidence available for various PI-based ART regimens in treatment-naive patients. We also discuss adverse effects and the use of PIs in special circumstances.