On December 1, the International Antiviral Society-USA (IAS-USA) updated its recommendations for the use of antiretroviral drugs for treatment and prevention of HIV in adults. In an accompanying editorial in JAMA, experts say that recent advances in the field—including a focus on simpler treatment regimens—“brings closer a future of comprehensive and equitable care for people living with HIV.”

Rajesh Gandhi, MD, of Massachusetts General Hospital and Harvard Medical School, and a team of international HIV clinicians and researchers reviewed relevant studies published or presented at conferences since the last update in 2022, along with information from drug companies. A key theme during this period was the adoption of long-acting antiretrovirals for treatment and pre-exposure prophylaxis (PrEP).

“New approaches for treating and preventing HIV offer additional tools to help end the HIV epidemic, but achieving this goal depends on addressing disparities and inequities in access to care,” the authors concluded.

Overall, the IAS-USA recommendations are comparable to the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV, which the U.S. Department of Health and Human Services (DHHS) updated in October. IAS-USA and DHHS both recommend that all people diagnosed with HIV should begin antiretroviral therapy as soon as possible after diagnosis, regardless of their CD4 T-cell count. If a person is ready, treatment can start on the same day.

For most people, recommended initial regimens include an oral integrase inhibitor, specifically bictegravir (part of the Biktarvy combination pill) or dolutegravir (sold alone as Tivicay), plus two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), preferably tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) and lamivudine or emtricitabine. Some people may be able to use just one NRTI. Dolutegravir plus TAF and lamivudine or emtricitabine is recommended during pregnancy, though women who become pregnant while taking Biktarvy can stay on it.

If a person acquires HIV while taking PrEP—uncommon, but possible if adherence is inconsistent—drug resistance testing should be done. The guidelines include specific recommendations for people receiving treatment for tuberculosis. Immediate initiation of antiretroviral therapy is advised for people with cancer.


People may switch regimens due to virological failure, side effects, a desire for greater convenience or to reduce cost. Most people who have achieved viral suppression should be able to take a single-tablet regimen that involves one pill once daily.

The long-acting injectable Cabenuva (cabotegravir and rilpivirine), administered by a health care provider once monthly or every other month, is an option for those who prefer not to take daily oral meds, those who struggle with adherence and those who experience stigma around taking daily pills. Cabenuva is generally not recommended for initial treatment or for those switching regimens with a detectable viral load, though some studies have shown that it can be a feasible option under those circumstances for people who are unwilling or unable to take daily pills.

People with extensive prior treatment experience, a history of virological failure or highly drug-resistant HIV typically need more complex regimens, which may include ibalizumab (Trogarzo), fostemsavir (Rukobia) or lenacapavir (Sunlenca).


IAS-USA provides updated recommendations for laboratory monitoring, management of substance use disorders and weight changes and use of statins for cardiovascular disease prevention for people living with HIV (based on recent results from the REPRIEVE trial). 

And there’s a new section on cancer, which now contributes to 20% to 30% of all HIV-related deaths.

For HIV prevention, daily or on-demand pills and long-acting injectable cabotegravir (Apretude) are effective options for people with increased likelihood of HIV exposure. The oral PrEP options are TDF/emtricitabine (Truvada or generic equivalents) and TAF/emtricitabine (Descovy), though the latter is not yet approved for people exposed to HIV through vaginal sex. The recommendations also include doxycycline post-exposure prophylaxis (doxyPEP) for prevention of sexually transmitted infections (STIs).

Throughout the recommendations, the authors discuss disparities and barriers that stand in the way of everyone having access to effective HIV prevention and treatment. They note that the recommendations were developed for high- and middle-income settings and may not be applicable in all low-income settings.

“HIV therapy continues to improve, with well-tolerated and highly effective oral regimens as well as long-acting injectable treatment for people who prefer to not take, or who have difficulty adhering to, daily therapy,” they wrote. “In addition, there are new approaches to maintaining health in people with HIV, including expanded indications for statins to reduce cardiovascular events and a new biomedical strategy, doxyPEP, to decrease STIs. HIV prevention through daily oral PrEP or long-acting injectables are crucial tools for ending the HIV epidemic in the U.S. and around the world. However, although the tools are available, efforts must be redoubled to reduce disparities and address inequities to realize the promise of ending the HIV epidemic.”

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