ART guidelines updated for HIV prevention, treatment

  • JAMA
  • 24 Jul 2018

  • curated by Liz Scherer
  • Clinical Essentials
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Takeaway

  • The International Antiviral Society–USA Panel has updated its 2016 antiretroviral therapy (ART) recommendations, highlighting rapid start (immediately after diagnosis) of treatment whenever feasible.
  • Early HIV diagnosis is essential. 

Why this matters

  • Clinicians treating newly HIV-infected patients should gain familiarity with new recommendations on rapid start, noting that after excluding active hepatitis, treatment can begin without results of supporting laboratory tests, including resistance testing.
    • Exceptions:1) HLA-B*5701 test findings needed if an abacavir-containing regimen is considered, 2) patients at-risk for immune reconstitution inflammatory syndrome in setting of active tuberculosis, cryptococcal meningitis, other opportunistic infections (OIs), 3) unclear HIV infections.

Key points

  • Rapid ART requires care linkage, coordination between testing/treatment settings, staffing, and services considerations.
  • Preferred rapid start agents: dolutegravir/tenofovir/alafenamide (TAF) or tenofovir/disoproxil/fumarate (TDF)/emtricitabine (or lamivudine) or bictegravir/TAF/emtricitabine or boosted darunavir TAF (or TDF)/emtricitabine (or lamivudine).
    • Consult 2016 recommendations for initiating ART in the patients with OIs.
    • For patients with malignancies, choice of ART should be guided by drug-drug interactions with antimicrobial/chemotherapy regimens.
  • Primary reasons for switching ART regimens: simplification, newly diagnosed comorbidities (or to prevent comorbidities), management of drug/other interactions.
    • Familiarity with switching guidelines in presence of non- and nucleoside reverse transcriptase inhibitors, virologic suppression/failures, and resistance is important.

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