• Lauren E Cain, Ellen C Caniglia, Andrew Phillips, Ashley Olson, Roberto Muga, Santiago Pérez-Hoyos, Sophie Abgrall, Dominique Costagliola, Rafael Rubio, Inma Jarrín, Heiner Bucher, Jan Fehr, Ard van Sighem, Peter Reiss, François Dabis, Marie-Anne Vandenhende, Roger Logan, James Robins, SterneJonathan A CJAC, Amy Justice, Janet Tate, Giota Touloumi, Vasilis Paparizos, Anna Esteve, Jordi Casabona, Rémonie Seng, Laurence Meyer, Sophie Jose, Caroline Sabin, Miguel A Hernán, and HIV-CAUSAL Collaboration.
• Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.
• Medicine (Baltimore). 2016 Oct 1; 95 (41): e5133e5133.

ObjectiveTo 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.DesignProspective studies of human immunodeficiency virus (HIV)-infected individuals in Europe and the United States included in the HIV-CAUSAL Collaboration.MethodsHIV-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.ResultsA 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.ConclusionOur 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.

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