EACS guidelines: New format and contents includes chemsex
26 November 2024. Related: Conference reports, Guidelines, HIV 17 Glasgow 2024.
EACS guidelines panelists (L-R): Victor Babes, Cristiana Oprea, Luís Mendão, Catia Marzolini, Esteban Martínez with co-chairs Juan Ambrosioni and Jürgen Rockstroh. HIV Glasgow 2024.
The latest edition of the EACS HIV guidelines (v12.1) was launched at HIV Glasgow 2024 in a special plenary that covered the most important and significant updates. [1, 2]
The guidelines have also been reorganised into two main parts and are now published online via an app and on an interactive website, with both the previous print and PDF versions now discontinued.
Part one includes five sections covering initial assessments, ART, drug-drug interactions, treatment and prevention of STIs (including PrEP and PEP) and paediatric HIV.
Part two includes nine sections covering the management of complications including cancer, cardiovascular health and metabolic complications, kidney, liver and pulmonary complications, cognition and mental health, ageing, and finally other complications (which include travel, transplantation, PROMS and sexual health).
The launch version is also open for comments for the next two months before being finalised.
A call for new members to work on future guidelines also resulted in 10 new panellists from over 100 applications.
Summary of changes in v12.1
A summary of the changes are included below, lightly edited from the current online version. [2]
Among these the most significant changes include new recommendations for PrEP dosing that notably expands to everyone starting with a double dose for rapid protection, and potentially 2:7 event-based dosing for people currently not able to use 2:1:1 dosing, although the panel discussion on this last point was unclear. [3]
A new section on chemsex should increase awareness in all countries and hopefully also support resourcing new services. Panellists noted that doctors in some countries had only become aware of chemsex after COVID-19.
Sections on managing TB, mpox and COVID-19 have been updated together with all drug-drug interactions.
Assessment of initial and subsequent visits
- CD4 T-cell count and HIV viral load should be monitored every 3 to 12 months.
- STIs should be screened every 3 to 12 months depending on exposure risk.
ART recommendations
- Abacavir- and raltegravir-containing regimens moved from recommended to alternative regimens.
- In case of PHI in the context of LA CAB PrEP, a darunavir/b regimen should be immediately started until resistance test is available.
- It is possible to switch to bictegravir- or dolutegravir-containing regimens even without full activity of 2 NRTIs.
- Recent data suggest possible use of CAB/RPV dual therapy in persons with A1 subtype.
- Lenacapavir and maraviroc are key in the therapeutic spectrum.
- RAL-containing regimens moved from recommended regimens to alternative regimens.
- BIC/TAF/FTC QD is now an alternative regimen in case of pregnancy.
- ART in TB/HIV coinfection: TXF/XTC + dolutegravir twice daily moved to recommended regimens.
PEP and PrEP
- In case of contact >15 min of mucous membrane or non-intact skin, PEP is recommended only if the source person is a viraemic HIV positive person or with serostatus unknown.
- Documented negative 4th generation HIV test can be done a week prior or on the day PrEP is initiated.
- Long-acting cabotegravir can be considered if available as an alternative to TXF/FTC. The effectiveness of LA-CAB has been evaluated in comparison to daily TDF/FTC in men, transgender women and cisgender women.
- In all populations and all regimens, PrEP should start with two tablets taken together as this achieves highly effective levels in all compartments 2 hours later.
- For men on on-demand PrEP, low adherence leading to PEP has been changed to non-compliance with 2-1-1 scheme.
Drug-drug interactions
- All DDI tables have been updated to include changes implemented in the HIV drug interaction website (University of Liverpool) in the past year. Apixaban was notably changed from red to amber with boosted ARV as the US label and real-life reports suggest that Apixaban can be used at a reduced dose with strong inhibitors. A QT interval prolongation risk was added for EFV to align with the label recommendation. EFV was shown to prolong the QT interval above the regulatory threshold of concern in homozygous carriers of the CYP2B6*6/*6 allele (516T variant).
- The administration of ARV in persons with swallowing difficulties was updated for TAF/FTC/BIC, TAF/FTC/EVGc, ABC/3TC/DTG and 3TC/DTG.
Viral hepatitis
- Additional guidance on HCV post-treatment monitoring in settings where liver stiffness measurement is available was provided.
- Recommendations for HDV treatment have been updated according to recently released EASL guidelines.
Coinfections and complications
- Results from a recently published clinical trial on the use of corticosteroids in TB meningitis have been discussed (N Engl J Med 2023;389:1357-1367). No modifications have been made on the recommendation to use corticosteroids as adjunctive therapy in this setting.
- The amphotericin B deoxycholate-based regimen has been removed from treatment options in cryptococcal meningitis, prioritising the single-dose liposomal amphotericin B (L-AMB)-based regimen in resource-limited settings and the 2-week liposomal amphotericin B (L-AMB) + flucytosine regimen in high-resource settings. Recommendations on alternative regimens in case of (L-AMB) or flucytosine unavailability have been edited.
- Therapeutic considerations on mpox have been modified and reformulated, pending results from ongoing clinical trials.
- The possibility to use alternative all-oral regimens for MDR-TB treatment in persons/groups not eligible to use BPaLM has been added, in accordance with recently released WHO recommendations.
- Recommendations for treatment of latent tuberculosis have been edited, prioritising once-weekly rifapentine+isoniazid regimen as treatment choice if rifapentine is available.
- Recommendations on IRIS prevention and management in cryptococcal meningitis and TB have been edited.
- A comment on the possible use of foscarnet in HSV and VZV infections has been added.
- Section on COVID-19 has been edited.
Paediatric HIV management, prophylaxis and infant feeding
- Added additional guidance on Hepatitis B status and immunity in the context of ART selection.
- Added information on PEP outside the neonatal period.
- Updated table 1 “Preferred and Alternative First Line Options in Children and Adolescents” to include the most recent treatment options for children and the newest licensing and formulation information.
- Minor edits in the other sections.
Sexually transmitted infections
- Wording of prophylaxis for bacterial STIs now suggests lower effectiveness of doxyPEP against gonorrhoea.
- Indication to consider CSF examination in isolated late-latent syphilis was removed.
Comorbidities and other topics
- A new section on chemsex has been introduced.
- Cardiovascular and metabolic health:
- Guidance on the primary prevention of cardiovascular disease has been updated in line with the EACS “Interim Guidance on the Use of Statin Therapy for the Primary Prevention of Cardiovascular Disease in People with HIV”.
- The algorithms for the management of hypertension and dyslipidaemia have been updated.
- Within the cancer section
- Anal cancer screening is recommended for MSM and trans women (TW) aged >35 years, men who have sex with women (MSW) and cis women (CisW) aged >45 years. The recommended screening interval is 1 year or up to 2 years if both cytology and high-risk HPV or HPV16 are negative.
- Cervical cancer screening interval has been revised to one year (or every three years if three consecutive negative PAP and CD4 ≥350 cells/mm3 and HIV-RNA <200 copies/mL or, in women >30 years, one negative PAP/HPV co-testing).
- The term metabolic dysfunction-associated steatotic liver-disease (MASLD) now replaces non-alcoholic fatty liver disease (NAFLD).
- Liver cirrhosis: management – this section now recommends HCC screening for everyone with cirrhosis, regardless of the cause. This also applies to people with cured HCV infection and/or with medically suppressed HBV replication.
- The surveillance algorithm for upper gastrointestinal tract endoscopy clarifies that the Baveno VII recommendations only apply to people with Child-Pugh A cirrhosis. People with Child-Pugh B and C cirrhosis should undergo annual gastroscopy independently of the Baveno VII criteria.
- In the Work-up and management of persons with increased ALT/AST, excluding syphilis as a potential cause has been included.
- Bone health – a new section combines three previous sections: (i) Bone disease: screening and diagnosis, (ii) vitamin D deficiency and (iii) fracture reduction.
- Travel – the travel section includes two online resources.
www.hivtravel.org
and
https://visaguide.world/news/countries-with-visa-restrictions-for-people-living-with-hiv/
comment
This update includes all the previous content and an excellent search facility to help navigate the new format.
References are more difficult to locate because they are no longer included with each section but are now collected together in a separate section at the end. As the references are neither numbered nor specifically referred to in the main text, a hyperlink in each section to the relevant references would be a helpful inclusion in future updates. A similar hyperlink back to the narrative text from each reference section would also be helpful.
References
- Ambrosioni J et al. Guidelines Session: 2024 Update and CV Risk Recommendations. Plenary session, HIV Glasgow 2024. Wednesday 13 November 2024.
https://virtual.hivglasgow.org/programme/guidelines-session-2024-update-and-cv-risk-recommendations (webcast) - EACS HIV Guidelines 2024, v12.1.
https://www.eacsociety.org/guidelines/eacs-guidelines/ - EACS guidelines: Double dose start for oral PrEP – rapid protection in two hours. HTB (20 November 2024).
https://i-base.info/htb/49351
This report was first published on 21 November 2024.