IAS-USA Releases 2018 Guidelines for HIV Treatment and Prevention

The International Antiviral Society-USA Panel (IAS-USA) has issued new guidelines on the prevention and treatment of HIV infection in adults, in an update to previous guidelines that had been released in 2016.

There are an estimated 1.1 million individuals in the United States living with HIV, though 1 in 7 do not know they are infected. The annual number of new HIV infections declined by 8% from 2010 to 2015, while access to antiretroviral therapy (ART) drugs has sharply increased in the United States and worldwide. Individuals living with HIV who are on ART treatment can maintain an undetectable viral load and prevent sexual transmission of the virus to an HIV-negative partner. Substantial advances in the development and use of ART drugs have been key to stemming the spread of the virus and helping those with HIV live longer, leading to an overall significant decrease in mortality, and making AIDS a chronic, manageable disease in many countries today. According to the Centers for Disease Control and Prevention (CDC), about 58% of those diagnosed with HIV in the United States were virally suppressed in 2014.

The IAS-USA Panel—a volunteer panel of international experts in HIV research and patient care—has released an update to their 2016 recommendations for treating and preventing HIV infection. The recommendations, published on July 24, 2018, in the Journal of the American Medical Association, are to replace prior recommendations and serve as treatment guidelines for clinicians. The updated guidelines are based on new research findings, drugs, approaches, and data which focus on adults 18 years or older who have HIV infection or at risk of becoming infected. In the 2018 guidelines, the panel continues its 2016 support for ART as the cornerstone of HIV prevention and treatment, with revisions that include:

• Updating initial regimens, focusing primarily on unboosted integrase strand transfer inhibitor (InSTI) regimens
• Encouraging rapid initiation of antiretroviral therapy, including same-day initiation, if feasible
• Recommendations against routine use of mycobacterium avium complex prophylaxis for those with advanced disease on effective antiretroviral therapy
• Recommendations for discontinuation of routine CD4 count lab testing once a patient has sustained undetectable HIV RNA levels for a year and has a CD4 count above 250 cells/ul
• Recommendations for an alternative for pre-exposure prophylaxis for those who are uninfected with HIV but remain at risk for infection to now include an episode-based approach where individuals can take preventive ART pills prior to exposure, and a follow-up pill once-daily for two days post-exposure

"The recommendations reflect the joint commitment of researchers working to collectively improve clinical outcomes and treatments available for all at-risk or infected HIV patients," said lead author Michael Saag, MD, director of the University of Alabama at Birmingham's Center for AIDS Research, in a recent statement. "We know that antiretroviral therapy is the cornerstone of prevention and management of HIV infection; but it's critical to continually evaluate new data and treatments for initiating therapy, monitoring individuals starting therapy, changing regimens and preventing HIV infection for those at risk, reaffirming the standard of providing the utmost treatment and care possible."

Care for HIV continues to evolve, study co-author Paul Volberding, MD, professor at the University of California San Francisco, added. And, as such, clinicians and patients need to apply the latest knowledge to keep pace with the ways in which it has changed. The guidelines, according to Dr Volberding, have been developed to provide a concise and current set of recommendations that capture the direction HIV care is taking.

In an accompanying editorial, author James Riddell IV, MD, notes that despite the availability of highly potent, single-tablet antiretroviral medications and a sophisticated medical infrastructure, too many individuals infected with HIV still are not receiving treatment and achieving viral suppression.

Of course, guidelines serve an important purpose, “however, guidelines serve only as a starting point, as evidenced by the fact that implementation has proved to be much more challenging,” writes Dr Riddell. “It is now clear that to effectively address the HIV epidemic, a multipronged approach is needed that includes new HIV prevention strategies (HIV pre-exposure prophylaxis, education regarding condom use), expanded HIV testing, rapid and immediate linkage to care when possible, viral suppression for persons who are HIV infected, and strategies to enhance adherence to therapy and retention in care.”