New UK guidelines: Treatment of HIV-1 positive adults with antiretroviral therapy (2012)
Simon Collins, HIV i-Base
In April 2012, the British HIV Association (BHIVA) published online the new adult treatment guidelines. This includes revisions to the initial draft published a month earlier for comment.
This is the first update since 2008, with the delay related to a new methodology that hopefully will enable NICE accreditation. This is a key objective if HIV care is to defer as a model for national care to the expertise in this document. Although the guidelines have always been evidence-based, the new methodology involved indentifying key clinical questions and related criteria, and then evaluating responses from the results of a more thorough a systematic literature search.
The guidelines focus on when to start initial treatment, which drugs to use, supporting patients on therapy and management of treatment failure. They include key recommendations and auditable outcomes and emphasise patient involvement in clinical decisions (section 3).
Section 8 is sub-divided to cover coinfection with TB, viral hepatitis, HIV-related cancer, neurocognitive impairment, renal disease, cardiovascular disease and women’s health.
Significant points in the new document include:
- ART can be used at any CD4 count (with no upper limit above 350) as an individual patient choice to reduce risk of infection to sexual partners.
- Current evidence prioritises tenofovir/FTC over abacavir/3TC for choice of dual NRTIs.
- Equal evidence supports one of four choices for the third component: atazanavir/ritonavir, darunavir/ritonavir, efavirenz or raltegravir.
- That outside of a clinical trial, there is insufficient evidence to recommend boosted PI monotherapy over current 3-drug stand-of-care.
- Age >50 years is no longer an independent factor for deciding when to start treatment – notably, the UK guidelines have dropped this just as the US DHHS guidelines included a new section on HIV and ageing.
These guidelines are also welcomed as a reference for minimum standard of care for HIV positive people and community advocates.
Although a small point in clinical terms, it also is encouraging to see the title of the guidelines reflect the more modern community preference to refer to HIV positive people rather than HIV-infected patients.
Links and PDF downloads:
Treatment of HIV-1 positive adults with antiretroviral therapy (2012)