In an effort to improve the lives of patients with HIV and further reduce the rates of transmission, an expert panel from the International Antiviral Society (IAS) has published updated recommendations on the use of antiretroviral therapy (ART), laboratory monitoring and screening, prevention, and management of older patients living with HIV. The updated recommendations were published in JAMA.1
IAS Recommendations: Methods and Overview
The 2020 IAS recommendations are based on new clinical evidence that has been published since the release of the 2018 IAS recommendations. This overview provides a brief summary on the new recommendations and contrasts them with the 2018 guideline.
ART Initiation and Clinical Considerations
Initial management of HIV includes 2 nucleoside reverse transcriptase inhibitors and an integrase strand transfer inhibitor (InSTI), or a 2-drug regimen of dolutegravir/lamivudine. Costs and/or healthcare access often guide the choice of therapy.
The IAS panel cite the utility of a 2- vs 3-drug initial therapy for HIV. The use of dolutegravir/lamivudine is recommended as an initial ART regimen. However, the limited use of this regimen in clinical practice indicates clinicians should watch patients closely to ensure adherence and virologic response.
In most people with HIV, the IAS strongly recommends the following initial ART regimens:
- Bictegravir/tenofovir alafenamide/emtricitabine
- Dolutegravir plus:
- Tenofovir alafenamide/emtricitabine
- Tenofovir disoproxil fumarate/emtricitabine
- Tenofovir disoproxil fumarate/lamivudine
- Dolutegravir/lamivudine with caveats
Individual clinical characteristics, preferences, financial considerations, as well as lack of available options can guide choice of ART regimen. For instance, patients with known or suspected pre-therapy multidrug resistance could start on darunavir/cobicistat/tenofovir alafenamide/emtricitabine.
Patients who are intolerant to InSTIs may also be considered for a regimen comprising doravirine/tenofovir disoproxil fumarate/lamivudine or doravirine plus tenofovir alafenamide/emtricitabine.
In the new guideline, the IAS suggests that switching ART regimen is recommended for some patients to reduce pill burden as well as to manage or prevent toxicity and drug-drug interactions. Similar to the 2018 recommendations2, the 2020 guideline indicates regimen switching is important for simplifying therapy, particularly in the setting of viral suppression without drug resistance as well as in the setting of viral suppression with archived drug resistance mutations. Additionally, switching regimens may be indicated in the setting of virologic failure.
The 2020 recommendations also offer suggestions on adjusting regimens while treating other concomitant disease. These include kidney disease, liver disease, cardiovascular disease, bone disease, weight gain, cancer and autoimmune disease, and solid organ transplantation. The panel recommends screening for and addressing modifiable risk factors when switching ART regimens to mitigate comorbid conditions.
There are very few differences between the new recommendations and the 2018 IAS guideline in regard to laboratory monitoring. In the 2020 guideline, the IAS panel continues to recommend routine HIV screening at least 1 time in people who have ever been sexually active or injected drugs.
Routine HIV screening should be more frequent in men who have sex with men (MSM), people who inject drugs outside needle-sharing programs, individuals with newly diagnosed sexually transmitted infections (STIs) or hepatitis C virus (HCV), and trans-feminine patients.
Following an HIV diagnosis and before starting ART, the IAS panel recommends laboratory monitoring to characterize the following:
- HIV stage
- General health: liver and kidney function, complete blood cell count, lipid levels, blood glucose, and pregnancy
- Co-infections: viral hepatitis A, hepatitis B, HCV, tuberculosis and STIs
Within 6 weeks of initiating ART, clinicians should consider testing for adherence and tolerability as well as measuring HIV RNA levels. HIV RNA level should be monitored every 3 months until viral suppression has been achieved for at least 1 year, and monitored every 6 months thereafter.
The IAS continues to recommend condoms for all genital penetrative sex acts to prevent STIs. Preexposure prophylaxis (PrEP) regimens, including tenofovir disoproxil fumarate/emtricitabine, are also recommended for all populations at risk of HIV. A double dose of tenofovir disoproxil fumarate/emtricitabine on day 1 followed by once-daily dosing is recommended for MSM.
For postexposure prophylaxis, the 2020 guideline recommends initiation with a 3-drug ART within 24 hours and up to 72 hours following exposure. This regimen should be continued for 28 days unless the absence of HIV infection in the source individual has been verified.
In contrast to the 2018 recommendations, the 2020 IAS recommendations offer guidance on the optimal treatment of older patients with HIV. Key recommendations made for this population include:
- Polypharmacy: Older patients often require additional agents to manage multiple comorbidities. Close monitoring of polypharmacy is important to prevent drug-drug interactions and non-adherence due to pill fatigue.
- Frailty: While HIV represents and independent predictor of frailty, a patient becomes increasingly at risk of increasing frailty over time. The panel recommends mobility and frailty assessment in patients with HIV aged 50 years or older; patients who are frail or pre-frail should undergo assessments frequently (eg, every 1-2 years).
- Neurocognitive Impairment, Mental Health, and Stigma: Patients with HIV have a higher risk of neurocognitive impairment. HIV is also associated with increased risk of loneliness and social isolation with depression, anxiety, and decreased quality of life. Periodic assessment of cognitive function, interventions to increase social interactions, and strategies to address stigma could be important for improving clinical outcomes in these patients.
Similar to the 2018 guideline, the 2020 recommendations note costs of HIV treatment represent a significant barrier to healthcare access. High-cost drugs may also reduce treatment engagement and adherence. The IAS recommend the following strategies to reduce HIV treatment costs:
- Prescribe generic antiretroviral drugs (when available)
- Split up co-formulations, as long as there is no reduction to adherence or increase in co-pays
- Assist with applications for industry- and government-funded patient assistance programs
Ending the HIV Pandemic
The 2020 recommendations cite recent goals and commitments made by the Joint United Nations Programme on HIV/AIDS to end the HIV epidemic. A current goal is to reduce the number of new infections per year (n=40,000) by 75% within the next 5 years and by 90% within the next 10 years.
The IAS states clinicians can participate in accomplishing this goal by “routinely testing for HIV in clinical settings, rapidly linking persons with HIV to care and prevention services, supporting patients so they can continue receiving ART and continue to have viral suppression, and prescribing PrEP so that people at highest risk can avoid acquiring HIV.”
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
1. Saag MS, Gandhi RT, Hoy JF, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2020 recommendations of the International Antiviral Society-USA Panel. JAMA. 2020;324(16):1651-1669. doi:10.1001/jama.2020.17025
2. Saag MS, Benson CA, Gandhi RT, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2018 recommendations of the International Antiviral Society-USA Panel. JAMA. 2018;320(4):379-396. doi: 10.1001/jama.2018.8431