Updated recommendations issued on ART for HIV infection

The International Antiviral Society-USA Panel recently released its updated 2018 recommendations on the use of antiretroviral therapy (ART) for treatment and prevention of HIV infection.

The panel is made up of 16 international volunteer experts in HIV care and research. To update its 2016 recommendations, the panel reviewed new evidence published through April 2018, as well as data presented at peer-reviewed conferences. The 2018 recommendations were published in the July 24/31 JAMA.

The panel noted that ART is recommended for almost all patients with HIV infection as soon as possible after diagnosis. To provide immediate therapy, adequate staffing, specialized services, and careful selection of medical therapy are required, the panel said. For initial therapy, an integrase strand transfer inhibitor plus two nucleoside reverse transcriptase inhibitors is generally recommended, but some patient circumstances, such as cost, can affect choice of treatment, the panel noted. The panel recommended an initial two-drug regimen only in rare cases, when a patient cannot take abacavir, tenofovir alafenamide, or tenofovir disoproxil fumarate. The panel recommended that CD4 cell count, HIV RNA level, genotype, and other laboratory tests be done at specified points before ART is started and during treatment. The panel also recommended that primary prophylaxis for Pneumocystis pneumonia be started for patients whose CD4 cell counts are below 200 cells/μL.

Treatment history, tolerability, adherence, and drug resistance history should be assessed before a regimen switch is instituted, the panel said, and a new regimen should include two or three active drugs. HIV viral load should be checked one month after a regimen switch to ensure effective maintenance of viral suppression, the panel said. Anyone who has ever been sexually active should be tested at least once for HIV, and those at ongoing risk for infection should be tested more frequently, the panel said. The panel also recommends preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine and appropriate monitoring for patients at risk for HIV.

The panel's recommendations, which are available free of charge online, include additional guidance on when to start ART, initial ART regimens, when and how to switch ART regimens, laboratory monitoring, engagement in care and ART adherence, and prevention of HIV infection. The panel noted that new treatments continue to be developed, that researchers continue to work on a potential cure for HIV infection, and that clinicians must be advocates for their patients with HIV infection.

“Advocacy should go beyond access to ART and include access to mental health and substance abuse services as well as efforts to end policies such as HIV criminalization that impede the ability to provide evidence-based care and prevention services,” the panel wrote.

An accompanying editorial noted that the shift toward immediate treatment is a recent development and that the availability of new, more potent drugs and drugs with less tendency to develop resistance has changed recommendations for initial courses of treatment. In addition, the editorialist noted that studies published since the last version of these recommendations have led to support for the use of some two-drug regimens as switch therapy in certain patients, although as noted they are not preferred as initial therapy. He also stressed that many challenges remain to implementing optimal treatment and management of HIV infection.

“It is now clear that to effectively address the HIV epidemic, a multipronged approach is needed that includes new HIV prevention strategies (HIV preexposure prophylaxis, education regarding condom use), expanded HIV testing, rapid and immediate linkage to care when possible, viral suppression for persons who are HIV infected, and strategies to enhance adherence to therapy and retention in care,” the editorialist wrote.