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- USA (IAS-USA) 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.
This article originally appeared on Infectious Disease Advisor