New HIV Guidelines Incorporate Rx and Prevention

Updated guidelines on the use of antiretroviral drugs (ARVs) incorporate both treatment and prevention for patients infected with HIV, according to a new study.

A panel of experts in HIV research and patient care convened by the International Antiviral Society–USA reviewed data published in peer-reviewed journals, presented by regulatory agencies, or presented as conference abstracts at peer-reviewed scientific conferences since the 2014 report, for new data or evidence that would change previous recommendations or their ratings.

The researchers, led by Huldrych F. Günthard, MD, of the University of Zurich in Switzerland, published their results in the July 12, 2016 Journal of the American Medical Association.

Key points

o Based on the data, the new guidelines support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count.

o They also recommend optimal initial regimens for most patients be 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs.

The guidelines also provide recommendations for special populations and in the settings of opportunistic infections and concomitant conditions. Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities.

In addition, the guidelines recommend laboratory assessments before treatment, as well as monitoring during treatment to assess response, adverse effects, and adherence. Also provided are recommendations to improve linkage to and retention in care.

o In terms of prevention, the guidelines recommend daily tenofovir disoproxil fumarate/emtricitabine for use as preexposure prophylaxis (PrEP) to prevent HIV infection in persons at high risk, which should be started as soon as possible after exposure, when indicated.

In conclusion, the authors note: “When used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. With these treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults.”

In an accompanying editorial, Dr. Kenneth Mayer and Dr. Douglas Krakower, of Fenway Health in Boston, MA, write: “The reason InSTIs have moved into a key position as first-line therapy is because these drugs have been shown to be highly effective, with the highest and most rapid rates of virologic suppression compared with protease inhibitors and nonnucleoside reverse transcriptase inhibitors, which previously had been mainstays of the antiretroviral ‘cocktail.’ Moreover, InSTIs are extremely well tolerated and several are coformulated with nucleoside analogs, allowing for potent, well-tolerated treatment to be delivered as a single pill taken once a day.”

They note that “Clinicians who take care of people living with HIV should become local experts regarding biobehavioral HIV prevention, especially because they may be taking care of partners of HIV-infected people. A challenge for effective HIV prevention will be to educate and engage primary care clinicians who do not see themselves as specialists in this realm, because they may be taking care of patients who may benefit from PrEP.”