BHIVA update adult ARV guidelines (November 2013)
Simon Collins, HIV i-Base
In November 2013, BHIVA updated the 2012 adult antiretroviral guidelines, largely to reflect the recommendations from the new hepatitis guidelines that were also published in the same month. [1, 2]
Changes, highlighted in yellow in the new PDF file, include:
- Elvitegravir/cobicistat is included as a preferred third drug for first-line treatment. This is based on non-inferiority results in studies compared to efavirenz and atazanavir/ritonavir.
- Rilpivirine is included as an alternative option for first-line treatment. This is largely because of the limitation for baseline viral load to be <100,000 copies/mL and concern over food requirements and potential interactions with antacids.
- New recommendations on ARV choice were based on a new analysis of comparative studies, and this is included in appendices 3 and 4.
- Recommendations for coinfection with HBV and/or HCV, and related auditable outcomes, have been updated to reflect the November 2013 coinfection guidelines.
- The discussion on when to start ART is expanded to explain why the CD4 threshold remains at 350 rather than increasing to 500. This includes referring to the importance of the START study in assessing both the benefits and risks of earlier treatment and that other factors could results in different recommendations outside the UK.
- The guidelines reaffirm that irrespective of CD4 count, ART should be available to all HIV positive people for whom the reduced potential for transmission is a factor in starting treatment.
- The timing of ART in patients starting treatment with a serious bacterial infection low CD4 is discussed to reflect recent research suggesting a caution to immediate ART, even though these were in a different health setting to the UK.
- Of note, a discussion of use of fixed dose combinations (FDC) compared to prescribing individual components separately, supported the benefits of FDCs, and noted the lack of evidence supporting separate dosing.
The full guidelines are available free online and are also published as a supplement to the 2014 edition of HIV Medicine. 
- British HIV Association (BHIVA). Treatment of HIV-1 positive adults with antiretroviral therapy (2012) (updated November 2013). HIV Medicine (2014), 15 (Suppl. 1), 1-85.
- Wilkins E et al for the BHIVA Hepatitis Guidelines Writing Group. British HIV Association guidelines for the management of hepatitis viruses in adults infected with HIV 2013. HIV Medicine 2013; 14 (Suppl 4): 1–71.