Updated guidance released on ART for HIV

Antiretroviral therapy (ART) for HIV should be started as soon as possible after diagnosis, ideally within seven days, including on the same day of diagnosis or at the first clinic visit if the patient is ready and no concomitant opportunistic infections are affected, according to new recommendations from the International Antiviral Society-USA Panel.

The panel, a group of volunteer expert physicians and scientists, updated its consensus recommendations for 2024 on HIV treatment, management, and prevention. The recommendations were published Dec. 1 by JAMA.

ART continues to be recommended for all patients with HIV, the panel said. For most people with HIV, initial regimens will be an integrase strand transfer inhibitor, bictegravir or dolutegravir, with two (and in some cases one) nucleoside or nucleotide reverse transcriptase inhibitors. The panel also provided specific recommendations for patients who are pregnant.

As previously recommended for patients with an opportunistic infection, ART should begin within two weeks of starting treatment in most cases. Exceptions to this recommendation are tuberculous meningitis and cryptococcal meningitis.

For those with tuberculous meningitis, treatment for tuberculosis and high-dose corticosteroids should begin immediately at diagnosis, and starting ART is recommended when tuberculous meningitis is under control, the panel said. For those with cryptococcal meningitis who can be closely monitored and treated for increased intracranial pressure and immune reconstitution inflammatory syndrome, ART initiation is recommended within two to four weeks after starting antifungal therapy, depending on response to antifungal therapy and other factors.

ART regimens may need to be changed due to virologic failure, adverse effects, convenience, or cost, the recommendations stated. Long-acting injectable therapy is available for those who prefer not to take daily oral medications and for people who have difficulty adhering to daily therapy.

For HIV prevention, oral (daily or intermittent) and injectable long-acting medications are effective options for people at higher risk for exposure. The recommendations noted that there are new tools for maintaining health and well-being among people with HIV, such as doxycycline postexposure prophylaxis to prevent sexually transmitted infections, as well as strategies to treat substance use disorders. The recommendations also cover laboratory monitoring in patients with established HIV, as well as weight gain and cardiometabolic comorbidities, among other topics.

The panel noted that laws criminalizing LGBTQ+ people, policies that criminalize harm reduction and drug use, and limitations on female reproductive health and transgender hormone-affirming care are hostile public policies that worsen disparities while restricting access to care and prevention.

The panel concluded, “New approaches for treating and preventing HIV offer additional tools to help end the HIV epidemic, but achieving this goal depends on addressing disparities and inequities in access to care.”