Coinciding with World AIDS Day on December 1, the International Antiviral Society-USA (IAS-USA) has released updated guidelines on the use of antiretroviral drugs for the prevention and treatment of HIV in adults. The revised guidelines, which can be accessed for free, were published in JAMA Network.

IAS-USA (not to be confused with the International AIDS Society) is a not-for-profit professional education organization perhaps best known for putting on the annual Conference on Retroviruses and Opportunistic Infections (CROI). Its HIV guidelines generally concur with the Department of Health and Human Services’ Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV.

To develop the revised guidelines, a panel of volunteer expert physician scientists were appointed to update the 2020 recommendations, taking to account new relevant research published in medical journals or presented at scientific conferences between January 2020 and October 2022.

The guidelines recommend initiation of antiretroviral therapy as soon as possible after an HIV diagnosis. Findings from the START trial—including a new long-term follow-up analysis—showed that starting treatment early, before immune function declines, leads to better outcomes.

For most people starting treatment, integrase inhibitor regimens “remain the mainstay of initial therapy,” the guidelines state. For people who have achieved viral suppression with a daily oral regimen, Cabenuva (cabotegravir plus rilpivirine), a long-acting injectable regimen administered by a health care provider every month or every other month, is now an option. Cabenuva is not currently recommended for people with a detectable viral load, but a pilot study suggests it could work well for those unable to achieve viral suppression due to challenges with treatment adherence.

“I think the incorporation of long-acting agents into HIV treatment and prevention is huge,” guidelines panel member and Infectious Diseases Society of America president Carlos del Rio, MD, of Emory University, told POZ.

Weight Gain 

While modern antiretroviral therapy is safe and generally well tolerated, it is not without side effects. Weight gain, in particular, is currently a hot topic in the HIV field. Weight gain and metabolic complications have been linked to certain antiretrovirals, including dolutegravir (sold alone as Tivicay and a component of the Triumeq, Dovato and Juluca combination pills) and tenofovir alafenamide (a component of Descovy and single-tablets regimens including  Biktarvy and Symtuza). However, the ways in which HIV and its treatment can affect weight and metabolism are not yet fully understood.

Recommendations for addressing weight gain and metabolic complications include documenting weight and body mass index when starting or switching treatment and then every six months to keep track of changes. People starting or switching treatment should be counseled about the possibility of weight gain and cardiovascular problems. Yearly screening for diabetes and cardiovascular risk is recommended for those taking integrase inhibitors.

“Until there are data proving benefit, switching regimens because of weight gain is not recommended,” the guidelines state. “Instead, lifestyle modifications, like exercise and diet intervention, are recommended.”

Other Concerns

Beyond medications, the guidelines also address various concerns of people living with HIV. “Barriers to care should be addressed, including ensuring access to [antiretroviral therapy] and adherence support,” the guidance states. “Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging.”

“Early diagnosis and initiation of [antiretroviral therapy] is particularly important in older persons because they are more likely to have a blunted immune response following [antiretroviral therapy] initiation and have a higher risk of serious non-AIDS complications,” the guideline authors add.

The guidelines recommend screening for underlying health conditions, impaired cognitive function, and poor mobility and frailty, which can increase the risk of falls. They also advise reviewing the medications people are taking for HIV and other conditions in an effort to simplify treatment, improve adherence, avoid drug interactions and reduce costs. In addition, “management of substance use disorder in people with HIV requires an evidence-based, integrated approach.”

“The aging of people with HIV has highlighted the need for integrated care models, including multidisciplinary teams of geriatricians, HIV specialists, pharmacists and allied health practitioners (such as physiotherapists) offering holistic patient-centered care,” the guidelines note.

The guidelines also cover HIV preexposure prophylaxis (PrEP). Current options include two combination pills: tenofovir disoproxil fumarate/emtricitabine (Truvada and generic equivalents) and tenofovir alafenamide/emtricitabine (Descovy), although the latter is not yet approved for people exposed to HIV via vaginal sex. A newer option is the long-acting injectable Apretude (cabotegravir), which is administered by a health care provider every other month.

Finally, the guidelines discuss how recent global health emergencies, including COVID-19 and monkeypox (recently renamed mpox), continue to have a major effect on people living with HIV and the delivery of HIV prevention, care and treatment services.

“Ending the HIV epidemic will require an equity approach that focuses resources on addressing societal disparities (for example, tackling poverty as an HIV prevention strategy), addressing stigma as a root cause of HIV risk, eliminating laws that target people with HIV, and ensuring access to care for all,” the guideline authors conclude.

Click here to read the full IAS-USA guidelines.
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