HIV Infection and AIDS Guidelines

Updated: Aug 20, 2020
  • Author: Shelley A Gilroy, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Guidelines

CDC Guidelines on HIV Screening in Men Who Have Sex with Men

The following are guidelines on HIV screening among men who have sex with men (MSM) [158]

  • The CDC concludes that the evidence, programmatic experience, and expert opinions are insufficient to warrant changing the current recommendation of annual screening for men who have sex with men (MSM) to more frequent screening (every 3 or 6 months).
  • Providers in clinical settings should offer HIV screening at least annually to all sexually active MSM.
  • Clinicians can also consider the potential benefits of more frequent HIV screening (eg, every 3 or 6 months) for some asymptomatic sexually active MSM based on their individual risk factors, local HIV epidemiology, and local policies.
  • Among MSM who are prescribed preexposure prophylaxis, HIV testing every 3 months and immediate testing whenever signs and symptoms of acute HIV infection are reported is indicated.
  • MSM who experience a specific high-risk sexual exposure or have symptoms of recent HIV infection should seek immediate HIV testing, and clinicians should be alert for the symptoms of acute HIV infection and provide appropriate diagnostic testing.
  • Tenofovir alafenamide (TAF)/emtricitabine (FTC) is now included as an alternative for pre-exposure prophylaxis (PrEP) in men who have sex with men (MSM).
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European AIDS Clinical Society Guidelines

The European AIDS Clinical Society (EACS) has issued updated guidelines on the management of HIV infection. In this latest version of the guidelines (version 10), a new drug-drug interaction panel has been introduced. The guidelines have six main sections, including a general overview table of all major issues in patients living with HIV infection; recommendations on antiretroviral treatment (ART); drug-drug interactions; and diagnosis, monitoring, and treatment of comorbidities, coinfections, and opportunistic diseases. [159]

Antiretroviral therapy

A new recommendation in the updated guideline favors an unboosted integrase strand transfer inhibitor (INSTI) with high genetic barrier (bictegravir [BIC] or dolutegravir [DTG]) as a third agent for therapy initiation in treatment-naïve individuals with HIV infection.

Two nucleos(t)ide reverse transcriptase inhibitors (NRTIs) plus doravirine (DOR) has been included among the recommended regimens.

Tenofovir disoproxil fumarate (TDF)/lamivudine (3TC) has been added as a backbone, when indicated.

DTG plus 3TC dual therapy has been upgraded as a recommended regimen.

High-genetic-barrier INSTI or protease inhibitors pharmacologically boosted with cobicistat or ritonavir (PI/b) are recommended as initial therapy for primary HIV infection if resistance testing is unavailable.

Ritonavir- or cobicistat-boosted darunavir (DRV/b) plus rilpivirine (RPV) has been included as a dual-therapy option.

Monotherapy with PI/b is not recommended.

Initiation of ART in patients with tuberculosis (TB) and HIV coinfection who have a CD4 cell count of more than 50/µL may be deferred up to 8 weeks after TB treatment has been started.

Tenofovir alafenamide (TAF)/emtricitabine (FTC), raltegravir (RAL) once daily, and bictegravir (BIC) have been added as potential drugs for postexposure prophylaxis (PEP).

TAF/FTC is now included as an alternative for pre-exposure prophylaxis (PrEP) in men who have sex with men (MSM) and transgender women.

Comorbidities

Screening for kidney disease should incorporate albumin/creatinine ratio for glomerular disease and protein/creatinine ratio for screening for and diagnosing antiretroviral-related tubulopathy.

Lipid targets have been updated in terms of the threshold for ART modification, from 20% 10-year risk for cardiovascular disease (CVD) to 10% 10-year risk for CVD.

Medical management of hypertension has been updated to include amended drug-sequencing suggestions and recommended drugs.

The workup of liver disease among individuals with HIV infection should now include a fourth step to include risk stratification based on risk prediction tools and transient elastography and an updated algorithm for surveillance of varices.

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Department of Health and Human Services

The U.S. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents has published guidelines to help providers integrate treatment as prevention (TasP) into their clinical practice. The Panel emphasizes the importance of screening and early diagnosis of HIV. In order for persons with HIV to benefit from early diagnosis, the Panel recommends that ART be started immediately or as soon as possible after diagnosis to increase the uptake of ART, decrease the time required to achieve linkage to care and virologic suppression for individual patients, reduce the risk of HIV transmission, and improve the rate of virologic suppression among persons with HIV. [160]

The DHHS recommendations include the following:

  • All persons with HIV should be informed that maintaining a plasma HIV RNA (viral load) of < 200 copies/mL, including any measurable value below this threshold value, with antiretroviral therapy (ART) prevents sexual transmission of HIV to their partners. Patients may recognize this concept as Undetectable = Untransmittable or U=U.
  • Persons with HIV who are starting ART should use another form of prevention with sexual partners (eg., condoms, preexposure prophylaxis [PrEP] for the HIV-negative sexual partner, sexual abstinence) for at least the first 6 months of treatment and until a viral load of < 200 copies/mL has been documented. Many experts would recommend confirming sustained suppression before assuming that there is no further risk of sexual HIV transmission.
  • When the viral load is ≥200 copies/mL, additional methods are needed to prevent transmission of HIV to sexual partners until resuppression to < 200 copies/mL has been confirmed.
  • Persons with HIV who intend to rely upon ART for prevention need to maintain high levels of ART adherence. They should be informed that transmission is possible during periods of poor adherence or treatment interruption.
  • At each visit for HIV care, clinicians should assess adherence to ART and counsel patients regarding the importance of ART to their own health as well as its role in preventing sexual HIV transmission.
  • Providers should inform patients that maintaining a viral load of < 200 copies/mL does not prevent acquisition or transmission of other sexually transmitted infections (STIs).
  • Providers should also routinely screen all sexually active persons with HIV for STIs, both for their own health and to prevent transmission of STIs to others.

The Panel has added DTG (dolutegravir) /3TC (lamivudine) to the list of Recommended Initial Regimens for Most People with HIV, except for individuals with pretreatment HIV RNA >500,000 copies/mL; who are known to have active hepatitis B virus (HBV) coinfection; or who will initiate ART before results of HIV genotype testing for reverse transcriptase or HBV testing are available.

Bictegravir/TAF (tenofovir alafenamide) /FTC (emtricitabine) has been added as a treatment option for persons with acute or recent HIV infection in cases where ART will be initiated before genotypic drug resistance testing results are available.

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