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EACS 2023: European guidelines fully revised (October 2023)

1 December 2023. Related: Conference reports, Guidelines, .

Simon Collins, HIV i-Base

The conference launched version 12 of the European guidelines developed by the European AIDS Clinical Society (EACS) which includes a major update to all sections.

The guidelines are available online as a pdf and web-based version and as a free App for iOS and Android devices. The pdf version continues to be translated into several different languages.

The guidelines also cover a large and diverse area geographically, with different national levels of access to care. The recommendations are often therefore broader than many national guidelines.

The 2023 version of the Guidelines includes updates of all existing sections.

The most essential changes are listed below and a more detailed summary of changes is listed online. [2]

ART section

  • Preference for second-generation INSTIs for initial ART, with boosted-PIs as an alternative.
  • Sustaining viral load <200 copies/mL without ART is included as an exception to the universal use of ART in chronic infection. (Elite viral controllers).
  • ART in primary HIV infection should be with a 30-drug rather than 2-drug combination.
  • Injectable cabotegravir/rilpivirine as a switch option with undetectable viral load.
  • Lenacapavir is included as a new option for people with viral failure.
  • Pregnancy guidelines include removing the caution about using dolutegravir and TAF and downgrade the use of abacavir. Language about breastfeeding still emphasises a low risk with undetectable viral load. Supported breastfeeding should include frequent viral load monitoring of the mother and infant. Formula milk can be used when needed. However, introducing solid food earlier than six months increases the risk of transmission.
  • TAF can be included in ART when treating TB.

HIV prevention

  • Reduced need for PEP if the risk is only oral sex.
  • Need to use 4th generation HIV testing and HBV serology before PrEP.
  • PrEP should be changed to ART if HIV infection is suspected.
  • PrEP users should be offered vaccines against HAV, HBV, HPV and mpox.
  • DoxyPrEP is included for prevention of STIs.
  • F/TAF and cabotegravir injections are included as alternative PrEP formulations when appropriate in some populations.

Drug-drug interactions (DDIs)

  • All DDI tables have been updated to include changes implemented in the HIV drug interaction website (University of Liverpool) in the past year.
  • A novel resource has been added for drug classes to simplify excessive medication burdens in older people living with HIV in by deprescribing under certain conditions.
  • Long-acting cabotegravir and rilpivirine incudes interactions that can change drug release and dosing recommendations after missed injections.
  • Lenacapavir has been added to all DDI tables.
  • A new table added for DDI between antiretrovirals and anti-infective drugs for OIs and STIs.

Co-morbidities

  • A new section on Patient Reported Outcome Measures (PROMs).
  • A new section on alcohol.
  • Updated guidance on the management of cognitive and central nervous system symptoms, travel, sexual and reproductive health, type 2 diabetes mellitus, cancer screening including anal cancer, chronic lung disease  and deprescribing.

Viral hepatitis

  • Updates on screening for complications, including HCC and HBV vaccinations.
  • Caution when switching HBV-active meds.
  • Removing the algorithm for acute HCV treatment.

Opportunistic Infections (OIs)

  • A new section on mpox.
  • COVID-19 section extensively updated.
  • TMP-SMX is an additional “preferred” treatment in toxoplasmic encephalitis. New discussion on diagnostic value of toxoplasma PCR in CSF and corticosteroids use in the context of large lesions with mass effect.
  • WHO-recommended single-dose liposomal amphotericin B+fluconazole is now an additional “preferred” regimen in resource limited settings for the treatment of cryptococcal meningitis. Recommendations on primary prophylaxis have been reformulated.
  • Liposomal amphotericin B+miltefosine has been added as an alternative regimen for the treatment of visceral leishmaniasis.
  • Updated recommendations on the ART initiation in the context of TB and cryptococcal meningitis.
  • Hyperlinks to the DDI table between selected anti-infective agents and ART.
  • A new comment on desensitization in the context of non-severe TMP-SMX allergy.
  • Minor stylistic changes and rephrasing throughout.

Paediatric care

  • Updated Table 1 on ART options for children.
  • Deleted Table 2 on alternative dosing as no longer relevant.
  • New section on “General principles of postnatal prophylaxis and infant feeding”.
  • Minor edits in the other sections.

comment

These updated guidelines are always welcomed.

Please refer to the full version for full details.

Reference

  1. EACS. EACS guidelines v12.0 (October 2023).
    https://eacs.sanfordguide.com (webpage)
    https://www.eacsociety.org/media/guidelines-12.0.pdf (PDF)
  2. Summary of changes in version 12.0/
    https://eacs.sanfordguide.com/contents/changes-v11-0-to-v11-1

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