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Switch in ART
A Switch in ART: Including Patient Preference in Best Practice

Released: February 04, 2025

Expiration: February 03, 2026

Justyna Kowalska
Justyna Kowalska, MD, PhD
Angelina Namiba
Angelina Namiba,
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Key Takeaways
  • With so many antiretroviral therapy options to choose from, it is now more important than ever to work collaboratively with patients to make sure they are receiving the best option for their individual health and life circumstances.
  • Active listening and shared decision-making are key skills that healthcare professionals can use to support appropriate antiretroviral therapy regimen changes for patients with viral suppression.

With the ever-increasing armamentarium available for HIV treatment, the field has come closer to being able to offer a truly individualized antiretroviral therapy (ART) regimen for each patient. As a result, optimizing therapy is about more than viral suppression—it is now about making sure each person is receiving an effective regimen that is also the most appropriate fit for their individual life circumstances and preferences.

Achieving individualized treatment for all requires skills that go beyond a deep understanding of available data and expert guideline recommendations, extending into the realm of so-called “soft skills” such as active listening and collaborative problem solving, particularly when the current ART regimen is not working for reasons unrelated to virologic suppression.

In this commentary, Justyna Kowalska, MD, PhD, infectious disease expert from the Medical University of Warsaw in Poland, and Angelina Namiba, Patient Advocate and Project Manager at the 4M Network of Mentor Mothers Living With HIV in the United Kingdom, discuss critical aspects of finding the ideal match between patient and ART regimen, including well-developed listening skills and proficiency in shared decision-making practices. In their discussion, they focus on tailoring ART switch strategies for people wanting or needing to change a virally suppressive regimen.

When the Person Living With HIV Wants a Different Regimen 

Justyna Kowalska, MD, PhD: We are going to discuss 2 general scenarios in the context of switching ART: when the patient is asking about a change and when the healthcare professional (HCP) is suggesting a potential change. Let’s start with the first situation, which is when a patient comes into the clinic and expresses the desire to change from a virologically suppressive regimen. As a patient advocate, what can you share about what HCPs need to know from the patient perspective in this setting?

Angelina Namiba: That is a good question because I think sometimes HCPs may inadvertently send the message that the only goal of HIV treatment is viral suppression and that if there is stable viral suppression, the task of the regimen has been fully achieved. It is certainly true that viral suppression is the most important goal of treatment, however, with continued research bringing new options into the fold and with the various changes that a person will experience over the course of a lifetime, there can be many reasons why a patient may want to maintain viral suppression in a different way, through the use of a different, similarly effective regimen. In this context, it is important to look beyond viral suppression alone.

This really comes down to the distinction between treating HIV and treating people with HIV. The HIV itself only needs a regimen that will suppress replication, but the person living with HIV needs a regimen that both suppresses HIV replication and works well in the context of their life circumstances.

Justyna Kowalska, MD, PhD: Yes, that is certainly true. There are many reasons why a regimen may not be fully meeting someone’s needs. Dosing could be a problem (if it is a twice daily regimen or has a food requirement), taking pills could be a problem (having pills in their home or swallowing them), or they may be experiencing a new health concern potentially related to the regimen.

To achieve the wider goals of treatment, HCPs need to take the time to understand what the person in front of them needs from their regimen that they are not currently getting when they request a change. This requires the ability to carefully and actively listen to what the person is saying, to ask clarifying questions if they are unsure, and to confirm with the patient that they have accurately interpreted their concerns. For HCPs, this situation provides an opportunity to listen to the patient, find out their thoughts about their treatment, and learn about how it fits into their lives.

Angelina Namiba: Another important skill is the ability to involve the patient in a shared decision-making process, so they can be an active participant in treatment decisions. There may be situations where the reason why the person is asking about a different regimen is not really an appropriate reason to change treatment, but in most cases, there will be a good reason. For example, there may be a specific aspect of a new regimen they recently learned about that sounds like a better fit for them than their current treatment.

Justyna Kowalska, MD, PhD: Yes, and when someone is asking about a new regimen, it provides an excellent educational opportunity for the HCP. For example, the person living with HIV may have heard about a new long-acting option that only needs to be given once every 2 months, and that may have prompted their curiosity about potentially not having to take a pill every day. As the HCP explains all of the details about long-acting injectable therapy, and what is and is not required of the patient, it could turn out to be of great interest to the patient, or the additional information may change their mind about it (for example, if they do not want to have to come to the clinic every 2 months to receive the injections).

This example highlights the importance of making sure the patient has an accurate view of what a given treatment strategy really looks like, because informed consent can only happen if the patient fully understands what the regimen involves.

In the situation where there is some reason why a particular switch regimen requested by a patient would put them at risk of harm, particularly in terms of loss of viral suppression and potential resistance development, the HCP is also provided with an educational opportunity to explain that risk to the patient.

There are also situations where a requested change may not put the patient at risk of loss of viral suppression, but data are lacking to definitively support the safety of the switch. A potential example is if a patient with a history of NNRTI resistance is expressing interest in switching to long-acting cabotegravir plus rilpivirine. In these cases, the HCP can explain that it is currently an area of uncertainty, but that with more data, it may prove to be a feasible option in the future. 

Angelina Namiba: This example also presents an opportunity. If the person living with HIV is bringing up the idea of a switch, that’s a chance to have an open discussion to learn which needs are not being addressed by the current regimen.

One other consideration for effective shared decision-making is the need to make sure that the patient understands the information you are sharing with them. This requires gauging the person’s health literacy and not assuming that what you are explaining makes sense to them. Patients can sometimes feel intimidated by the medical setting and may be reluctant to say that they do not understand. Of course, there are also patients who are not interested in the details and prefer to let the HCP make the decision. Each situation is different.

When the HCP Suggests a Regimen Change 

Justyna Kowalska, MD, PhD: Now let’s shift gears to discuss when the HCP feels that a switch regimen is needed to better tailor HIV treatment to a patient’s current medical situation. This can happen when comorbidities emerge that could be exacerbated by a particular ART regimen or if a comorbidity requires another medication that is not compatible with the ART regimen.

There is always a risk with a regimen switch, so it is important for HCPs to think through these decisions very carefully to make sure that the anticipated benefit is worth the change and to make sure that the switch regimen has a comparable barrier to drug resistance and fits with the person’s individual treatment history. But in this situation, patients may sometimes be reluctant to change from a regimen that they have relied on, particularly if they have been on the same treatment for many years.

Angelina Namiba: Yes, if a person has been taking the same regimen for a long time, they may have a strong attachment to it, maybe even a feeling that it saved their life. Asking them to let go of something that has been working well for them for so long can be difficult.

It also may have taken them a long time to get to the stage of having a reliable, well tolerated, effective, stable regimen—to a suppressed and settled situation. But over time, as patients age, comorbidities may creep in that could be exacerbated by a previously well tolerated regimen. The HCP may see the signs, for example in blood work, before the patient experiences any problems.

Justyna Kowalska, MD, PhD: Exactly. So, from the patient perspective, what would be helpful for HCPs to know about the experience of the person living with HIV when their HCP suggests a regimen change and how can the HCP support them if they feel reluctant to change?

Angelina Namiba: One important approach would be to give the patient time to adjust to the idea of a potential new regimen. Letting them know that they do not need to change therapy right away but that it would be good to think about possibly changing, maybe in the coming months.

The HCP can provide them with useful information about the new regimen—how it is similar and how it differs from what they are currently taking, and that you as the HCP have confidence that it will maintain viral suppression for them.

It is also helpful to reassure them that if the new regimen leads to any unexpected side effects, they can switch back or look at other options.

Finally, linking them to peer support, if possible, so that they may be able to speak to other patients who have made a similar switch, can be extremely helpful.

Justyna Kowalska, MD, PhD: Those are great suggestions. In my practice, I never push a switch on a patient with virologic suppression. The most important factor is that the patient feels well and has a psychological acceptance of their treatment. Treatment for HIV may have been initiated during a time when the patient felt vulnerable and really needed support, and when the regimen proved to be effective for them, it likely improved their lives. The way a patient sees their treatment is different from the way the HCP sees it. For the HCP, treatment is just medication, but for the patient, it is a moment in time, it is a support they needed, it is a source of security. We need to take a holistic view that considers the psychological aspects of HIV care.

With that in mind, if there is an issue such as high cholesterol that may be exacerbated by the HIV regimen and the patient does not want to switch, I would address it another way, for example, by adding a statin, rather than coercing the patient to switch. It is critical to balance the patient’s needs and preferences, without force or coercion.

Angelina Namiba: Absolutely. Yes, it is about engaging with patients, giving them choices, and not making assumptions about what they might prefer. We know that HCPs want their patients to have the very best treatment available, but what appears to be the best option on paper is not necessarily the best option for a given individual.

Justyna Kowalska, MD, PhD: In 2025, there is so much more that individuals living with HIV can expect from their treatment beyond viral suppression. With the array of ART regimens available and continuing to emerge, HCPs can feel empowered to start conversations about how treatment is working for their patients and listen carefully to the answers so they can identify those expectations and needs. In this way, HCPs and their patients can collaborate to find the best treatment option, tailored to match each unique lifestyle and circumstance.

Your Thoughts?
How do you support your patients with viral suppression when they request a regimen change? What about when you feel that a patient would benefit from switching to a new treatment and the patient feels a strong attachment to their current regimen? Get involved in the discussion by posting a comment.

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What is your approach when a person who has experienced long-term and continued virologic suppression on their current ART regimen but previous NNRTI failure with resistance expresses interest in switching to a different regimen?

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