New IAS–USA Guidelines Confirm Commitment to Universal HIV Treatment

In 2010, the International AIDS Society–USA was among the first major organizations to endorse universal treatment for HIV-infected individuals. Now, the organization (newly renamed the International Antiviral Society–USA) has focused its most recent set of treatment guidelines on the accumulation of evidence that supports broad use of antiretrovirals, both in HIV-infected persons and in HIV-uninfected persons at risk for infection.

The new guidelines endorse treating all individuals with established HIV infection, irrespective of clinical and immune status, although the panel acknowledges that in some subgroups, including elite controllers and long-term nonprogressors, the evidence of benefit from treatment is still either inconclusive or absent. The confirmed benefits of combination antiretroviral therapy (ART) for HIV-infected individuals include reduced risks for HIV-related events, HIV-unrelated infections and malignancies, and premature death. Treatment also reduces the risk for HIV transmission to uninfected sexual contacts.

In individuals with acute opportunistic infections, prompt initiation of ART has been confirmed to reduce mortality, except in two groups of patients: those with cryptococcal meningitis, for whom early HIV treatment has been shown to increase mortality, and those with tuberculous meningitis, for whom the optimal timing of treatment is still unclear.

What to Start

Like the 2010 guidelines, the latest IAS–USA guidelines recommend ART combinations based on efavirenz, ritonavir-boosted darunavir, ritonavir-boosted atazanavir, and raltegravir. Alternative regimens include those based on lopinavir/ritonavir, as well as the newest coformulated once-daily tablets containing rilpivirine and elvitegravir. Based on anecdotal evidence, the panel suggests that withholding tenofovir from postmenopausal women may be prudent, given this group's increased risk for fragility fractures.

Monitoring Viral Loads

An additional update in the guidelines concerns management of treated patients with persistent low-level viremia in the range of 50 to 200 copies/mL. Because this finding could be interpreted to indicate evolution of drug resistance, the panel suggests that a change of regimen be considered.

Pre-Exposure Prophylaxis (PrEP)

A new section of the guidelines addresses PrEP as an emerging area of therapy and notes that its success has been repeatedly demonstrated to be adherence-dependent. More specific advice regarding the use of tenofovir/FTC for PrEP (a newly approved indication) is still forthcoming.