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BackgroundWe assessed whether quadruple or triple-class therapy for the initial treatment of HIV-1 infection provides a virological benefit over standard triple therapy in patients with very high plasma viraemia. The assessment was made based on a national observational HIV cohort in the Netherlands.MethodsInclusion criteria were age ≥18 years, treatment-naive, plasma viral load (pVL) ≥500,000 copies/ml and initiation of quadruple or triple therapy between 2001 and 2011. Time to viral suppression, defined as pVL<50 copies/ml, was compared between the two groups using Kaplan-Meier plots and multivariate Cox regression analysis.ResultsA total of 675 patients were included: 125 (19%) initiated quadruple and 550 (81%) triple therapy. Median pVL was 5.9 (IQR 5.8-6.1) log(10) copies/ml in both groups (P=0.49). 22 (18%) patients on quadruple and 63 (12%) on triple therapy interrupted the treatment regimen because of drug-related toxicity (P=0.06). Median time to viral suppression was 5.8 (IQR 4.6-7.9) and 6.0 (4.0-9.4) months in the patients on quadruple and triple therapy, respectively (log-rank, P=0.42). In the adjusted Cox analysis, quadruple therapy was not associated with time to viral suppression (HR 1.07 [95% CI 0.86, 1.33], P=0.53). Similar results were seen when comparing triple- versus dual-class therapy (n=72 versus n=601, respectively).ConclusionsInitial quadruple- or triple-class therapy was equally effective as standard triple therapy in the suppression of HIV-1 in treatment-naive patients with very high viraemia and did not result in faster pVL decreases, but did expose patients to additional toxicity.

Original publication





Antiviral therapy

Publication Date





1609 - 1613


Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Center for Infection and Immunity Amsterdam, the Netherlands.


ATHENA National Observational Cohort Study, Humans, HIV-1, Viremia, HIV Infections, Anti-HIV Agents, Treatment Outcome, Drug Therapy, Combination, Antiretroviral Therapy, Highly Active, Viral Load, Adult, Middle Aged, Female, Male, Kaplan-Meier Estimate