New guidelines on HIV prevention, treatment released

The International AIDS Society-USA released clinical guidelines on preventing and treating HIV, noting that the 2 approaches should complement each other on reducing the spread of the disease.

The guidelines and an accompanying editorial appeared in a special issue on HIV and AIDS in the Journal of the American Medical Association.

Prevention guidelines state:

• All adults and adolescents should be tested for HIV at least once. Those at increased risk of infection should undergo repeated testing;
• If diagnosed, a person should start antiretroviral therapy;
• Patients should be supported via individualized risk assessment and counseling, help with partner notification, and periodic screening for other common sexually transmitted infections;
• People at high risk of HIV infection should undergo preexposure prophylaxis and individualized counseling on risk reduction. The recommended regimen is daily emtricitabine/tenofovir disoproxil fumarate. High-risk populations include those living in areas with high HIV incidence rates, a recent diagnosis of incident sexually transmitted infections (STIs), users of injection drugs or shared needles, or recent use of non-occupational postexposure prophylaxis;
• Injection drug users should receive clean needles and use syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists, and participate in detoxification and drug cessation programs; and
• Postexposure prophylaxis is recommended for anyone who has sustained a mucosal or parenteral exposure to HIV from a known infected source. It should begin as soon as possible.

Treatment guidelines state:

• Recommended initial regimens for infected individuals include 2 nucleoside reverse transcriptase inhibitors (NRTIs; abacavir/lamivudine or tenofovir disoproxil fumarate/emtricitabine) and a third single or boosted drug, which should be an integrase strand transfer inhibitor (dolutegravir, elvitegravir, or raltegravir), a nonnucleoside reverse transcriptase inhibitor (efavirenz or rilpivirine), or a boosted protease inhibitor (darunavir or atazanavir);
• An alternative regimen of boosted protease inhibitor monotherapy is generally not recommended, but NRTI-sparing approaches may be considered;
• Suspected treatment failures should be rapidly confirmed while the patient is receiving the failing regimen. Clinicians should evaluate reasons for failure before switching therapy; and
• Switching regimens due to adverse effects, convenience, or to reduce costs should not jeopardize potency of the antiretroviral drugs.

An editorial about integrating these guidelines into practice stated that prevention and treatment approaches should be complementary. Behavioral approaches should support the effectiveness of antiretroviral therapy, preexposure prophylaxis, and postexposure prophylaxis, while treatments should contribute to prevention through mechanisms that behavioral interventions cannot.

“Established community-led approaches can support and be used in delivering biomedical interventions. Incorporating prevention within services that have historically focused on treatment may be challenging in some cases,” the editorial states. “The 2014 IAS-USA recommendations reinforce the need for physicians, other clinicians, and health care workers to be supported so they can fulfil their responsibilities in effectively providing patients with behavioral and biomedical strategies for HIV prevention.”