Updated HIV Treatment Guidelines Include Stronger Recommendation for Acute Infection

On February 12, 2013, the U.S. Department of Health and Human Services antiretroviral therapy (ART) guidelines panel issued an update to the adult and adolescent HIV treatment guidelines. Among the key changes are additional information about the most recently approved antiretroviral agents and a recommendation that newly infected people with HIV should be offered combination ART.

The guidelines continue to recommend treatment for all people with HIV, both to reduce the risk of disease progressionand for the prevention of HIV transmission. However, the panel states, "Patients starting ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence" and "Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors."

The full guidelines are available online. The document includes an introductory section that summarizes the latest changes.

Key additions and revisions include:

• Updated recommendation on integrase inhibitor resistance testing for people on a failing integrase inhibitor-based regimen.
• Guidance on use of a new genotypic HIV tropism assay to predict co-receptor (CCR5 or CXCR4) use, especially before starting a CCR5 antagonist such as maraviroc (Selzentry).
• Recommendation that the NNRTI rilpivirine (Edurant, also in the Complera coformulation) should only be used by people with pre-treatment viral load <100,000 copies/mL.
• Recommendation that the recently approved Stribild (elvitegravir/ tenofovir/emtricitabine/cobicistat) single-tablet regimen is an alternative for ART-naive people with pre-treatment creatinine clearance >70 mL/min (an indicator of good kidney function).
• Strengthened recommendation that people with "early" HIV infection -- meaning both acute (before seroconversion) and recent (within the first 6 months -- should be offered ART, along with evidence supporting this change.
• Updated recommendations on the use of efavirenz (Sustiva) during pregnancy and intravenous zidovudine (AZT; Retrovir) during labor, mirroring recent changes to the perinatal guidelines.
• New information in the drug-drug interaction section on use of ritonavir (Norvir) and cobicistat as pharmacokinetic enhancers to increase levels of other antiretroviral drugs.
• Updates to drug interaction tables, including the addition of known and predicted interactions involving elvitegravir/cobicistat and other drugs.

The guidelines panel will be accepting feedback on the revisions through February 26, 2013. Send comments to JLIB_HTML_CLOAKING with the subject line "Comments on Adult and Adolescent ARV Guidelines."

2/15/13

Sources

DHHS. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Updated February 12, 2013.

AIDSinfo. HHS Adult and Adolescent Antiretroviral Treatment Guidelines Updated. AIDSinfo At-A-Glance. February 12, 2013.