HTB

US HIV guidelines updated (October 2017): dropping “HIV-infected”

22 January 2018. Related: Guidelines.

Simon Collins, HIV i-Base

The main US HIV treatment guidelines (HHS) were updated in October 2017. [1]

All changes are highlight in yellow in the PDF version of the quidelines.

Main changes include:

  • Person-first language. Removing the offensive term “HIV-infected” when referring to HIV positive people and adopting more affirmative person-based language throughout. This is a way of reducing stigma and showing respect for individuals who are living with HIV by focussing on the person instead of the disease. Although this might seem a small point to many health professionals, similar changes were adopted by BHIVA from 2012 and by EACS from 2013.

  • Starting ART

    • The classifications for initial therapy have been changed from three options of  recommended, alternative, and other to:
      1. Recommended for most people; and
      2. Recommended in certain situations.
    • Integrase inhibitor-based regimens are now recommended as first therapy for most people with HIV.
    • NNRTI and PI-based combinations are now only recommended in certain clinical situations.
    • Longer-term safety data have clarified that TAF has less bone and kidney toxicity but TDF is associated with lower lipid levels.
    • Updates have been made throughout the section with new safety and clinical trial data.
    • Monotherapy with any single ARV should not be used due to increased risk of virologic failure and drug resistance.
    • Dual therapy using lamivudine plus either dolutegravir or boosted darunavir is not recommended, but is an alternative requiring closer monitoring in people who are not able to use other NRTIs.
    • Efavirenz is (finally) no longer banned during the first trimester of pregnancy.
    • The classifications of ART regimens have been changed from Recommended, Alternative, and Other to:
      (i) Recommended regimens for most people; and
      (ii) Recommended regimens in certain situations. (Specific regimens are listed in Table 6 of the guidelines.)

    Virologic Failure

    • “Low-level viremia” was defined at <200 copies/mL.
    • Several sections were restructured.
    • The importance of maintaining HBV treatment in people with hepatitis B virus (HBV)/HIV coinfection was emphasised.
    • Ibalizumab and fostemsavir are included as pipeline compounds for people with .

    Changing treatment

    • Discussion of several studies using two-drug maintenance therapy.
    • Clinical trial data involving investigational combinations are discussed.

    Coinfection with HIV HBV and/or HCV

    • Both sections have been updated to discuss recent reports regarding reactivation of hepatitis B virus (HBV) infection in persons with HBV/hepatitis C virus (HCV) coinfection after starting interferon-free HCV therapy.
    • Individuals with chronic HBV infection should receive treatment for HBV with NRTIs that are active against both HIV and HBV before starting HCV therapy.
    • For the HCV section, interactions between new HCV direct-acting agents and ARV drugs have been added to Table 12.

    Adherence

    • The section on adherence has been revised to also include HIV care.
    • The importance of doctors working with a multidisciplinary team to understand barriers to care.
    • New evidence-based interventions and best practices to improve adherence are summarised.
    • In people with adherence problems, dolutegravir and boosted darunavir are mentioned given their high genetic barriers to resistance.

    Additional updates have been made to the following sections:

comment

i-Base presented research on the use of HIV positive compared to HIV infected at the IAS conference in 2010, [1] 

This contributed to the changes in BHIVA guidelines from 2012 and EACS guidelines from 2013. 

References

  1. DHHS guidelines for the use of antiretroviral agents in adults and adolescents living with HIV (October 2017).
    https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0
  2. Collins S et al. HIV positive vs HIV infected: reducing barriers to clinical research through use of appropriate and accurate language. AIDS 2010, Vienna. Abs THPE0516.
    http://www.abstract-archive.org/Abstract/Share/3331

DHHS guidelines for the use of antiretroviral agents in adults and adolescents living with HIV (October 2017).
https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0

Links to other websites are current at date of posting but not maintained.