Contemporary once-daily single-tablet and multi-tablet antiretroviral therapy regimens were associated with similar rates of viral suppression among people with HIV enrolled in Washington state Medicaid, according to a study published in Open Forum Infectious Diseases. The findings suggest clinicians and health systems may want to weigh factors beyond pill count—including cost, patient preference and social barriers to care—when selecting treatment.
Single-tablet regimens (STRs) have become commonplace in HIV care, in part because reducing pill burden has historically been associated with better adherence. However, much of that evidence predates widespread use of contemporary integrase inhibitor-based regimens. Single-tablet options can also cost substantially more than multi-tablet regimens (MTRs), raising questions about whether a one-pill difference translates into long-term clinically meaningful benefits.
“For most patients, there probably isn’t any meaningful difference in efficacy between HIV regimens that include one pill versus two pills once a day,” said study author Matthew R. Golden, director of the University of Washington’s Center for AIDS and STD, in an interview with this news orgnization. “Many of us [clinicians] default to using single-tablet regimens. However, those regimens are often substantially more expensive than two pill regimens.”
To compare the effectiveness of STRs and contemporary once-daily MTRs, Golden and his and colleagues at the Washington State Health Care Authority linked 2023 Washington state Medicaid administrative data with statewide HIV RNA surveillance data for 2,874 adults with HIV. The team defined viral suppression as an HIV RNA level below 200 copies/mL, with analyses being adjusted for factors including age, sex assigned at birth, race, ethnicity, time since HIV diagnosis, housing status, health care system, geographic region, and receipt of Ryan White services.
Overall, 2,599 people with HIV (or 90.4% of the Medicaid enrollees) were virally suppressed. Among those receiving regimens recommended as first-line therapy in 2025 US guidelines, suppression was 91.6% with the single-tablet regimen bictegravir/emtricitabine/tenofovir alafenamide, compared with 88.9% among people receiving first-line MTRs. After adjustment, the difference was not statistically significant.
The clearest disparity was associated not with pill burden but with housing status. Viral suppression was consistently lower among people experiencing unstable housing. Within that particular group, suppression was nearly identical with bictegravir/emtricitabine/tenofovir alafenamide and first-line multi-tablet therapy, at 78.8% and 78.2%, respectively. Among people with stable housing, the corresponding rates were 94.1% and 91.3%, with no significant adjusted difference.
“The association of low viral suppression with unstable housing is a pretty consistent finding across studies—I think that it’s really hard to adhere to HIV treatment if you don’t have a stable place to live,” explained Golden. “We did not see that the single tablet regimens were better than two tablet regimens in people who were unstably housed. Taking one fewer pill per day is probably not a potent intervention for improving viral suppression in the population at greatest risk for not being suppressed.”
The reseachers noted that in Washington’s Medicaid program, bictegravir/emtricitabine/tenofovir alafenamide (the most commonly used antiretroviral therapy in the state) is around 77% more expensive than selected dolutegravir-based multi-tablet alternatives, concluding that any virologic advantage of contemporary single-tablet therapy appears small and does not necessarily justify routinely favoring higher-cost formulations. The cost of these treatments may therefore warrant greater consideration when regimens are otherwise clinically appropriate.
In light of the study’s findings, Golden hopes that a “more holistic approach to health”, in which health care spending is redirected appropriately, might be the future of HIV treatment.
“We need to do much more to integrate data on effectiveness, cost, and patients’ needs and preferences into how we make decisions related to HIV treatment and prevention,” he said. “From a policymaking perspective, we need to be much more disciplined and creative in how we spend money. We should make cost information more available to medical providers and patients to help them make informed, rational decisions; implement policies to decrease the use of high-cost medicines when they offer little or no benefit; and advocate for spending at least some portion of the money saved through more rational healthcare spending on things like housing and food, things that are essential to living a safe and happy life.”
The researchers noted that the observational analysis could not account for factors that may have influenced regimen selection, including antiretroviral resistance, comorbidities, drug interactions, kidney function, treatment history and participants’ total medication burden. The findings may also not be generalizable beyond Washington, where Medicaid has no co-payments for medications or care and substantial resources are devoted to case management and other support services.
The authors reported no relevant conflicts of interest.
