EACS releases three updated management guidelines (December 2009)
Simon Collins, HIV i-Base
The European AIDS Clinical Society publishes three management guidelines that make extensive use of summaries, bullet point list and supportive tables to produce resources that are easy to follow resources.
The three main updates (version 5) were launched at this years conference.
PDF versions are now available to download from the societies website. Additional tables not included in the PDF and printed booklets are also available online.
The main changes to each guideline are outlined below
- A check list for initial and routine clinic management and a new flow chart for assessing and supporting a patients readiness to start ARV treatment. This includes the importance of asking about depression and mental health, and alcohol and recreational drug use.
- In primary infection, although a CD4 count <350 three months after infection is included as a criteria to start treatment, the guidelines recognise that most patients are likely to wait at least until six months.
- Treatment is recommended for any patient with a CD4 count <350, and at between 350-500 in patients older than 50 years, coinfection with HCV, HBV or other listed health complications.
- A new section focuses on HIV and TB coinfection.
- Switching drugs for toxicity is overly cautious for anyone other than naive patients, perhaps underestimating the importance of tolerability when modifying treatment however pre-treatment someone may be.
- PEP is recommended ideally within 4 hours of exposure, and not later than 48 hours. Surprisingly there is no reference to viral load of the HIV-positive partner as a factor in assessing risk.
Prevention and management of non-infectious comorbidities
This management guideline has expanded considerably, now addressing many of the comorbidities associated with an older HIV cohort, especially cardiovascular, renal, hepatic, metabolic, neoplastic, done and mental health complications. Recommendations are not graded based on the quality of evidence.
- Screening sections have been expanded for renal, bone, neurocognitive disorders, depression and cancer.
- Lipid management is covered in a separate table, which notably does not include triglyceride management due to less evidence suggesting elevated TG as an independent risk factor for clinical complications.
- Bone screening refers doctors to the FRAX calculator (www.shef.ac.uk).
- Kidney screening includes eGFR at baseline and a new recommendation to include dipstick testing.
- Many additional tables are available as web resources (ie for neurocognitive screening, lipoatrophy treatments etc).
The main changes in the hepatitis coinfection guidelines include:
- To start appropriate ARVs when CD4 count is <500 c/mm3 in people who need HBV treatment.
- That this is likely to be lifelong unless the patient is HBV eAg+ who may clear HBV and that treatment could be cautiously stopped six months after conversion to eAg.
- New information on hepatitis D (HDV) which increase the risk of fibrosis progression in HBV infection.
- That people with CD4 count < 350 should probably start ARVs prior to HCV treatment to increase the chance of success (SVR).
- Early HCV treatment is recommended for HIV-positive people identified in acute HCV infection.
- Non responders (< 2 log HCV RNA drop at week 12) should stop treatment to wait for new options.
- People who relapse can consider retreating with longer duration.
- That HIV is no longer a contraindictation for liver transplant and that timely referral to transplant lists is therefore important.