BHIVA guidelines for adults (2025 interim update)

22 October 2025. Related: Early access, Guidelines.

Simon Collins, HIV i-Base

On 1 October 2025, BHIVA published an interim update to the 2022 adult HIV guidelines. [1]

The main changes, mainly in sections 5 and 7 on choice of ART, are based on over 55 new references and are highlighted in green in the PDF version. Changes made in 2023 about cardiovascular health are still highlighted in yellow.

Injectable ART

This update includes a new option to use CAB/RPV-LA off-label for some people with detectable viral load on oral ART. This is in situations where there is a risk of HIV progression on oral ART.
Viral load monitoring can be reduced to every 4 – 6 months in some circumstances.
The criteria to use CAB/RPV-LA still includes shared decision making due to the small but serious risk of treatment failure even with perfect adherence. Having both BMI >30 and sub-type A1, or a significant risk of HBV infection are exclusion criteria for CAB/RPV-LA.
A new section discusses the use of oral lead-in dosing and situations when this might be relaxed. Oral dosing is also discussed in circumstances when injections are delayed.
Lenacapavir has been added as an option for treating multiple-drug resistance (MDR).

Other ART changes

Abacavir has been removed from preferred first-line ART unless clinically needed. The guidelines now recommend proactively switching away from abacavir when this is still being used. For example, to switch anyone currently on DTG/ABC/3TC to dual DTG/3TC.
Dual dolutergavir/lamivudine is now recommended as first-line ART at any CD4 count, dropping the previous caution at VL >500,000 copies/mL. The guidelines still do not recommend using DTG/3TC dual ART in people with a history that includes the M184V mutation.
People with historical K103N and not recommended to use DTG/RPV dual ART.
That so long as there is no resistance to INSTI or NNRTIs, TDF and xTC can be recycled in the presence of: isolated M184V/I; K65R/N (or K70E/G) plus M184V/I; L74V +/- M184V/I; A maximum of two TAMs plus M184V/I.
To not use tenofovir DX in people with severe osteopenia (T<–2.0), a history of fragility fracture, a 10-year probability of a major osteoporotic fracture >5% and/or a 10-year probability of a hip fracture >1%.
A new review on the risk of HBV reactivation in people with evidence of past HBV infection.
To actively inform anyone switching ART with an undetectable viral that they can return to their current combination if for any reason the new combination causes problems. (This has always been a community recommendation.)

comment

Although the main 2022 guidelines were produced using the GRADE approach, setting PICO questions and an evidence review, the interim updates are more informal, based on more recent evidence selected by the writing panel.

The inclusion of off-label CAB/RPV-LA with detectable viral load for people who have difficulty on oral ART is important and is also included in US DHHS, IAS-USA and EACS guidelines.

The 2025 update to the EACS guidelines were also published this month and are important for the many other aspects of HIV management that are not covered by BHIVA. [2]

References

BHIVA. BHIVA guidelines on antiretroviral treatment for adults living with HIV-1 2022. HIV Med 2022; 23 Suppl 5: 3-115.
https://bhiva.org/clinical-guideline
EACS guidelines major update: ART, OIs, on demand PrEP for women, weight gain, HIV-2, pregnancy, infant feeding, sleep disorders and more. HTB (22 October 2025).
https://i-base.info/htb/52581