What's New in Adult and Adolescent, Perinatal HIV Guidelines

AIDSinfo, a portal from the National Institutes of Health, has outlined changes that have been made in the last year to adult, adolescent, and perinatal HIV guidelines.

Adults and Adolescents

Based on community input, the guidelines have been updated to include people-first language as a way of “reducing stigma and showing respect for individuals who are living with HIV by focusing on the person instead of the disease.” Where the guidelines used to say, “HIV-infected person,” they will now say, “person with HIV.”

On March 27, the HHS Adults and Adolescents Antiretroviral Guidelines Panel announced that bictegravir, the HIV-1 integrase strand transfer inhibitor recently approved by the FDA, is recommended as initial treatment as part of a single-tablet, once-daily regimen that includes tenofovir alafenamide and emtricitabine. It is not recommended for individuals with creatinine clearance less than 30 mL/min or with severe liver impairment, and it is not approved for individuals under age 18.

The classification of antiretroviral therapy (ART) regimens recommended for initial therapy have been changed from Recommended, Alternative, and Other to Recommended Initial Regimens For Most People With HIV and Recommended Initial Regimens in Certain Clinical Situations.

The panel now emphasizes that monotherapy with any antiretroviral (ARV) drug should not be used because of increased risk of virologic failure and treatment resistance. Efavirenz is no longer prohibited during the first trimester of pregnancy.

Other updated guidelines include:

• Clinicians are advised to maintain patients with hepatitis B virus (HBV)/HIV coinfection on ARV drugs that are active against HBV when switching ART regimens upon virologic failure.
• Traditionally, the guidelines have recommended starting ART-naïve patients on a regimen with at least 3 active drugs. Now, several studies note that people with HIV who have sustained viral suppression with no drug resistance can be maintained on regimens with 2 active drugs.
• The Adherence to Antiretroviral Therapy section has been revised to Adherence to the Continuum of Care. This section stresses the importance of clinicians working collaboratively with a multidisciplinary team to understand and overcome barriers to adherence of the continuum.

Perinatal

On March 27, Guidance for Counseling and Managing Women Living With HIV in the United States Who Desire to Breastfeed was added to the Perinatal Guidelines. While the panel does not recommend breastfeeding for women with HIV, the section provides tools to help providers who counsel women living with HIV on the potential risks associated with breastfeeding and to provide a harm-reduction approach if women choose to breastfeed.

The guidelines also added the following 3 sections: Maternal HIV Testing and Identification of Perinatal HIV Exposure, Antiretroviral Management of Newborns With Perinatal Exposure or Perinatal HIV Infection, and Diagnosis of HIV Infection in Infants and Children.

People-first language was also incorporated into these guidelines. Other updated guidelines include:

• Recommendations for safer conception among couples who attempt conception.
• When a pregnant woman presents on an elvitegravir/cobicistat regimen, providers should consider switching to a more effective regimen. If the regimen is continued, viral load should be monitored frequently and therapeutic drug monitoring may be useful.
• To rapidly suppress viral load to reduce the risk of perinatal HIV transmission in women with acute HIV infection during pregnancy, the panel recommends initiating a ritonavir-boosted protease inhibitor-based regimen or a dolutegravir-based regimen with tenofovir disoproxil fumarate/emtricitabine.
• The new section, Diagnosis of HIV Infection in Infants and Children, provides recommendations and detailed content on timing and types of tests used to diagnose HIV in infants and children.