New guidelines from the International Antiviral Society recommend antiretroviral therapy for ALL HIV-infected patients
Sponsoring Organization: International Antiviral Society–USA (IAS-USA)
Target Population: Clinicians who treat HIV-infected patients
- Antiretroviral therapy (ART) is recommended for all HIV-infected patients, including those with acute HIV infection—but not yet for elite controllers.
- In patients with opportunistic infections and AIDS-defining illnesses, including cancers, ART should be started as soon as possible, usually within 2 weeks of diagnosis. In patients with cryptococcal meningitis, recent data suggest a slight delay may be warranted.
- Initial regimens should include two nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs; abacavir/3TC or tenofovir/FTC) plus an integrase strand transfer inhibitor (dolutegravir, elvitegravir/cobicistat, or raltegravir), a ritonavir-boosted protease inhibitor (atazanavir or darunavir), or a non-nucleoside reverse transcriptase inhibitor (efavirenz or, if pretreatment HIV RNA is <100,000 copies/mL, rilpivirine). Alternative regimens are also offered.
- NRTI-sparing or NRTI-limiting regimens are discussed; although such options may be used in special circumstances, they are not routinely recommended.
- A nice discussion of individualizing therapy in patients with cardiovascular, renal, and bone disease is included.
- New data are summarized on treatment of active and latent tuberculosis infection in HIV-infected patients, highlighting issues related to drug interactions.
- Stable patients on ART warrant less-frequent laboratory monitoring. For example, CD4-cell–count testing is optional once HIV RNA is suppressed for >2 years and CD4 counts are consistently >500 cells/mm3.
- In patients with multidrug-resistant virus, a potent boosted protease inhibitor should be included in the new regimen; if an active regimen can be constructed using a combination of other classes, NRTIs need not be included.
Günthard HF et al. Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society–USA Panel. JAMA 2014 Jul 23/30; 312:410. Link.