by Jeffrey T. Kirchner, DO, AAHIVS, AAHIVM Chief Medical Officer

October 20, 2020

Featured Literature:

Saag MS, Gandhi RT, Hoy JF et al. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2020 Recommendations of the International Antiviral Society–USA Panel. JAMA. Published online October 14, 2020. doi:10.1001/jama.2020.17025

The results of clinical trials of antiretroviral therapy (ART), including new drugs and formulations for HIV treatment and prevention are presented and/or published on a continual basis. This paper is the updated IAS-USA Guidelines which historically have been published in JAMA concurrently with the biannual IAS meeting. This is an update of the July 2018 guidelines. The authors reviewed over 5000 citations on ART and included 549 that were published or presented at peer-reviewed conferences. A panel of 15 experts in HIV research and patient care reviewed these new data which are the basis for updates to previous IAS-USA guidance. Specific areas addressed included: recommendations for initiating ART, monitoring patients starting on therapy, changing ART regimens, special considerations for older PWH, and preventing HIV infection for persons at risk. The guidelines continue to recommend starting ART as soon as possible for all individuals with HIV with detectable viremia. Initial therapy can be with a 3-drug or a 2-drug regimen, which should include an integrase strand transfer inhibitor. Effective and safe options are available for patients who are pregnant and those with specific clinical conditions, such as kidney, liver, or cardiovascular disease. For the first time, the guidelines recommend long-acting ART (rilpivirine and cabotegravir) injected once every 4 weeks or 8 weeks pending FDA approval and availability. For individuals at risk for HIV, PrEP with an oral regimen either daily or “on-demand” is recommended and pending FDA approval, with an IM injection of cabotegravir every 8 weeks. As in the past, clinical and laboratory monitoring before and during ART for safety and efficacy is recommended. Switching ART due to virological failure is uncommon these days and recommendations for switching therapies for convenience and other reasons are included. Lastly, the guidelines address issues related to HIV care amidst the COVID-19 pandemic.

Author’s Commentary:

The IAS-USA HIV treatment guidelines remain a solid and complementary adjunct to the more detailed DHHS HIV guidelines. The IAS guidelines have some very good and concise recommendations related to ART use and comorbidities including bone, liver, and renal disease, weight gain, and organ transplantation. Injectable formulations of ART are endorsed for prevention and treatment while FDA approval is pending. There are also excellent tables discussing when and how to switch ART. As in the past, there are certain clinical nuances in the IAS guidelines that differ from the DHHS recommendations. I would recommend that all HIV care providers review the full document which is available at the link above and incorporate these recommendations into their clinical practices.

The author has no conflicts of interest to disclose.

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