Saturday, 16 July 2016

Updated HIV guidelines integrate treatment and prevention

Updated HIV guidelines integrate treatment and prevention

Dr K K Aggarwal

The International Antiviral Society-USA panel on antiretroviral (ARV) drug therapy for HIV infection has released updated recommendations, which for the first time, have integrated treatment and prevention. The guidelines say that ARVs remain the cornerstone of HIV treatment and prevention and when used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. The guidelines “Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults2016 Recommendations of the International Antiviral Society–USA Panel” are published July 12, 2016 in JAMA. Some key recommendations are: • Antiretroviral therapy (ART) should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count. • The recommended optimal initial regimens include an integrase strand transfer inhibitor (InSTI) + 2 nucleoside reverse transcriptase inhibitors (NRTIs). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs. • ART should be started within the first 2 weeks after diagnosis for most acute opportunistic infections, with the possible exception of acute cryptococcal meningitis. • 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. • Laboratory assessments are recommended before treatment, and monitoring during treatment is recommended to assess response, adverse effects, and adherence. If ART is being initiated on the first clinic visit, all laboratory specimens should be drawn prior to the first dose of ART; resistance testing results should be used to modify the regimen as necessary. Recommended pre-ART tests include CD4 cell count, plasma HIV-1 RNA, serologies for hepatitis A, B, and C, serum chemistries, estimated creatinine clearance rate, complete blood cell count, urine glucose and protein, sexually transmitted infection screening, and fasting lipid profile. Genotypic testing for reverse transcriptase and protease resistance mutations is also recommended pre-ART. • Systematic monitoring of time to care linkage following initial HIV diagnosis, retention in care, ART adherence, and rates of viral suppression is recommended in all care settings. • Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals. Daily, rather than intermittent, tenofovir disoproxil fumarate/emtricitabine is the recommended PrEP regimen. Detailed sexual, substance use, and medical histories are important for deciding whether to provide PrEP. • The guidelines recommend vaccination against hepatitis A and hepatitis B for those who are not immune and human papillomavirus vaccination. • Postexposure prophylaxis is recommended as soon as possible after exposure without waiting for confirmation of HIV serostatus of the source patient or results of HIV RNA or resistance testing. Postexposure prophylaxis regimens should be continued for 28 days, and HIV serostatus should be reassessed at 4 to 6 weeks, 3 months, and 6 months after exposure.

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