HHS vs IAS-USA Guidelines for HIV

Segment Description: Joseph Eron, MD; Paul Sax, MD; W. David Hardy, MD; Eric S. Daar, MD; Ian Frank, MD, discuss the updated US HHS guidelines regarding antiretroviral agents and rapid initiation, as compared with the IAS-USA Guidelines.

Joseph Eron, MD: Eric, tell us, what are the HHS [US Department of Health and Human Services] guidelines right now?

Eric S. Daar, MD: For treatment?

Joseph Eron, MD: Yes.

Eric S. Daar, MD: OK, before I say that though, let me just say there’s 1 other branch point that actually was very relevant in my practice in which we take care of lot of very difficult patients—not difficult patients but patients with difficult problems. They’re homeless, they’re dealing with substance abuse, alcoholism, psychiatric disease.

Ian Frank, MD: Adolescents.

Eric S. Daar, MD: I don’t have a lot of adolescents, but they have similar issues. The group of people that I really worry about when I start them on a therapy that they wouldn’t the medications, right? Or maybe never even come back. And for me that used to be a big branch point. It sort of boosted PI [protease inhibitors] versus other. But now with the data on dolutegravir as a barrier to resistance, I’m perfectly comfortable moving forward with that. And I think bictegravir may turn out to be exactly the same way. We don’t have as much data. So suddenly, as you say, all those things that were important before with comorbidities and drug-drug interactions and now barrier to resistance have all gone away, and they are preferred options to really meet all those needs.

Ian Frank, MD: And Paul made the point earlier that the prevalence of integrase-associated resistance is very low. I still think that we should be doing resistance, testing at baseline. Paul will argue against it. But I still think that there are a number of reasons why it’s still valuable. But I think it doesn’t influence our treatment decisions very much anymore.

Eric S. Daar, MD: I agree with you, not Paul.

Paul Sax, MD: Am I allowed to defend myself?

Ian Frank, MD: No, not now. We’ll come back to that.

Eric S. Daar, MD: What are the current guidelines? The current guidelines are dolutegravir with abacavir and 3TC lamivudine in a single tablet, dolutegravir with TAF-FTC [tenofovir and emtricitabine], and bictegravir with TAF-FTC. And those are really the US guidelines right now.

Paul Sax, MD: You know the HHS still has raltegravir in there.

Eric S. Daar, MD: One addition—and raltegravir remains on the HHS guidelines but not IAS-USA [International Antiviral Society].

Paul Sax, MD: Exactly, and that’s 1 place where they differ substantially. And since I’m on the IAS-USA panel with some of my colleagues here, I’m going to say I don’t really see how raltegravir fits when you’re comparing it with bictegravir and dolutegravir. It’s 2 pills; it can’t be co-+formulated. Residence does occur, especially, you know, to class resistance. So it does, yeah, we have a long track record with it, and when it came out in 2007, it transformed HIV therapeutics. But these second-generation integrase inhibitors are better.

W. David Hardy, MD: Just a resistance difference is one that would make you stop want to use it, despite the pills.

Eric S. Daar, MD: Yeah, I’m not pushing back on that because I agree with you, but the 1 issue that we sort of started to talk about, and maybe we need to talk a little more about is, women of childbearing age potential.

Joseph Eron, MD: Yeah, we’re going to get to that in literally just a minute.

Paul Sax, MD: Can I critique the DHHS guidelines a bit more?

Joseph Eron, MD: Yeah.

Paul Sax, MD: So I actually don’t think there’s much role for abacavir any more. You know abacavir was always a little less well tolerated than tenofovir, even independent of a hypersensitivity. And the signals on cardiovascular risk are concerning enough that I probably wouldn’t use it. Why use it? You know, it really does not seem to have much of a role any longer. And then so both raltegravir and abacavir kind of have fallen down.

Joseph Eron, MD: It certainly doesn’t, if you read the guidelines. You know, for most people it just—there are too many caveats.

Paul Sax, MD: Exactly. You know and you still have to do an HLA-B*57:01 test, which isn’t a big deal, but it is another test.