The International Antiviral Society-USA Panel has updated its recommendations for the management and prevention of HIV infection to reflect the most current data on new treatment regimens and strategies. The recommendations have been published in the Journal of the American Medical Association.
Key recommendations include the following:
- Rapid initiation of antiretroviral therapy (ART), within 7 to 14 days of new diagnosis, is preferred in ambulatory patients who are committed to starting ART.
- Structural barriers that delay initiation of therapy should be removed so that patients can begin ART at their first clinic visit after diagnosis. These barriers should be continually assessed for their effects on adherence with ART, and these assessments should also be done in individuals receiving PrEP.
- ART should be started within 2 weeks after diagnosis of most opportunistic infections; however, primary prophylaxis for Mycobacterium avium complex is no longer recommended in individuals with viral suppression.
- The recommended initial ART regimens include bictegravir/tenofovir/emtricitabine (evidence rating AIa), dolutegravir/abacavir/lamivudine (evidence rating AIa), and dolutegravir plus tenofovir/emtricitabine (evidence rating Ala).
- Adherence and tolerability of the regimen and the HIV RNA level should be evaluated within 6 weeks of beginning ART and then every 3months until viral load is <50 copies/mL for one year, after which testing can proceed bi-annually.
- Before making any changes in the patient’s regimen, a review should be made of the ART treatment history, regimen tolerability, complications, and results of prior resistance tests (evidence rating AIa).
- Patients taking older ART medications should be questioned carefully regarding known toxicity. If the older regimen is well tolerated, there is no recommendation to change.
- In patients with NRTI mutations, a switch from a boosted protease inhibitor to a regimen including drugs with a low genetic barrier to resistance (eg, NNRTI or raltegravir) is not recommended (evidence rating AIa).
- HIV viral load should be checked 1 month after a change in made in regimen to ensure virologic suppression is being maintained (evidence rating BIII).
- Resistance testing should be done while taking the failing regimen or within 4 weeks of stopping. Once resistance is verified, a prompt switch to another active regimen is recommended based on present and past resistance testing.
- Quarterly screening for asymptomatic STIs for all populations with high rates of bacterial STIs, and incomplete condom use.
- Noncash incentives as part of combination strategies are effective in increasing adherence with ART regimens and tiered strategies using risk stratification are recommended.
- Pericoital tenofovir disoproxil fumarate/emtricitabine PrEP, also known as on-demand, event-driven, or “2-1-1 dosing” may be considered as an alternative to daily PrEP for men who have sex with men with infrequent sexual exposures (evidence rating AIa).
- Abacavir-based PEP is not recommended unless the exposed patient is known to be negative for the HLA-B*5701 allele (evidence rating AIII).
- “Clinicians who care for patients with HIV have a major role in advocating for programs and their patients at the local, national, and international levels,” write the investigators. They add that “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.”
Saag MS, Benson CA, Gandhi RT, et el. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2018 recommendations of the International Antiviral Society-USA Panel. JAMA. 2018;320:379-396.