New BHIVA guidelines: B/F/TAF now preferred first-line ART and reduced HIV monitoring in the UK during COVID-19

Simon Collins, HIV i-Base

On 1 May 2020, BHIVA published the first guidelines specifically for the management of HIV care in the UK during COVID-19.

The new guidelines include specific recommendations for monitoring and treatment that are briefly summarised below. The document also includes recommendations for health workers providing services, for example for service planning and providing leadership during the epidemic.

The most significant changes are reducing monitoring and the related recommendation to use the bictegravir-based fixed dose combination B/F/TAF as first-line combination (so long as this is medically appropriate). This assumes good adherence and no side effects.

Please refer to the full document published on the BHIVA website in PDF format, together with other information and statements about COVID-19. This is linked below and the full draft is also published as an html page in this issue of HTB.

Summary of new HIV management guidelines

ART should continue being used without interruption. This includes by people diagnosed with COVID-19. Services will continue to provide HIV drugs to all people living with HIV.
ART should not be switched or stopped unless there is a medical need to do this. Lopinavir/r (Kaletra) is not recommended as treatment for COVID-19.
Monitoring CD4 and viral load tests will be deferred, unless this is clinically needed (for example, to start or change treatment). This assumes good adherence and no side effects.
Minimise ART switching until after COVID-19 unless clinically needed. This assumes good adherence and no side effects.
Providing six-months of ART. This assumes good adherence and no side effects.
Viral failure (to change ART) is now defined as two viral load results above 200 copies/mL or a single rebound above 1000 copies/mL. ART with low barrier to resistance (NNRTI-based ART) should be changed to ART with a high barrier to resistance. These generally include dolutegravir-, bictegravir- or boosted darunavir-based combinations.
B/F/TAF (bictegravir/tenofovir-alafenamide/emtricitabine, trade name Biktarvy) is proactively recommended for first-line ART. Exceptions include new pregnancy, drug interactions or intolerance.
Monitoring after new or changed treatment should involve:
– A two-month initial drug supply.
– Viral load monitoring after one month.
– Follow-up with four months drug supply.
All prescribing during COVID-19 should be later reviewed by a multidisplinary team (MDT).
Limitations or problems with home delivery can be overcome with collection from pharmacy, Royal Mail and courier services.
Supporting government policies about population health for reducing transmission of COVID-19 including self-isolation/distancing generally and shielding for people who are extremely vulnerable.
Shielding is recommended for people living with HIV who have a CD4 count <50 cells/mm³, other serious comorbidities or a detectable viral load.

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These guidelines are welcomed.

Over the last two months, NHS services have been considerably restructured to minimise care that is defined as ‘non-essential’. This has involved moving many doctors, nurses and supporting staff and laboratories from HIV care to COVID-19.

Some changes have worked well to ensure HIV care remains high and the risk of COVID-19 is reduced. The move to telephone/virtual HIV consultations has reduced the need for travelling and use of public transport, especially since the UK shut-down from 23 March. Virtual appointments might now be easier to make.

People who are stable on effective HIV treatment should have no difference in their overall care. This is defined as having an undetectable viral load for the previous six months on ART that is manageable and that is without complications or side effects. Luckily, this covers the majority of people who are living with HIV in the UK.

When the situation is more complicated and face-to-face consultations are needed, or additional tests, HIV clinics are now less busy and appointments can be arranged with minimal waiting time and minimal contact with other clients and staff.

References

BHIVA. BHIVA COVID-19 ART guidelines 1May 2020.
https://www.bhiva.org/BHIVA-COVID-19-interim-adult-antiretroviral-guidance
https://www.bhiva.org/file/5eac2b1e84f0f/BHIVA-interim-ART-guidelines-COVID-19-01052020.pdf (drirect PDF)

Note: This HTB article was first published on 1 May 2020 and edited on 4 May to emphasise that B/F/TAF is recommended as the preferred combination for first-line ART. Other alternatives are still recommended when switching ART.