HIV Guidelines Say Antiretrovirals for All, Prophylaxis for Some

Marcia Frellick

October 23, 2015

BARCELONA, Spain — Every person infected with HIV should be treated with antiretroviral therapy immediately after diagnosis, according to updated guidelines from the European AIDS Clinical Society (EACS), unveiled here at the 15th European AIDS Conference.

The update also endorses pre-exposure prophylaxis for HIV-negative men who have sex with men and for transgender people who use condoms inconsistently with casual partners or with HIV-positive partners who are not on treatment.

Prophylaxis can also be considered for HIV-negative heterosexual women and men who use condoms inconsistently and who are likely to have HIV-positive partners not on treatment, on either a continuous or on-demand basis.

The recommendations in the guidelines, which are updated annually, closely resemble those in the guidelines released by the World Health Organization on September 30, as reported in Medscape Medical News.

Doctors Starting New Conversations

Two updated recommendations — that all people infected with HIV begin antiretroviral therapy as soon as possible and that those at "substantial" risk be offered prophylaxis — will change conversations doctors have with their patients around the world.

Under the old guidelines, treatment did not begin until CD4 counts fell below a certain threshold. Physicians will now have to contact patients with high CD4 counts and start them on treatment as soon as possible, said Jürgen Rockstroh, MD, from the HIV outpatient clinic at the University of Bonn in Germany, who is vice chair of the guidelines committee.

In the United States, the "guidelines have been saying that for a long time," he told Medscape Medical News. "The Europeans have been a little more reluctant, but national British guidelines are also recommending that now."

The updated recommendations were developed after results from the START trial — one of the largest trials of HIV infection ever conducted — were released earlier this year.

In START, antiretroviral therapy started immediately after diagnosis in asymptomatic HIV-infected patients with CD4 counts above 500 cells/mm³ cut the risk of developing AIDS or other serious illnesses in half. In fact, when the benefit became clear, the trial was stopped.

Direct-Acting Antivirals Inspired Hepatitis C Update

Advances in the treatment of hepatitis C infection with direct-acting antivirals have led to a phasing out of interferon, so the coinfection section in the guidelines has been updated.

People who are coinfected with HIV and hepatitis C should be treated not when they develop advanced liver disease, but during earlier fibrosis stages, Dr Rockstroh explained.

"There's a strong recommendation for treating F2 or higher, but even for patients with F0 and 1, we recommend it," he said. Many countries recommend treatment at F3 or 4, so these guidelines go beyond common practice in some regions. "Because you have access issues, we understand if people wait," he pointed out.

The updated guidelines might inspire patient activism in areas such as prophylaxis, said Anton Pozniak, MD, from the Chelsea and Westminster Hospital in London, United Kingdom, who is cochair of the guidelines committee.

"People can take these recommendations to their authorities and say, 'In the EACS guidelines, based on the data, prophylaxis is recommended. What are we doing about it in our country for high-risk individuals?' That conversation is now going on in many countries across Europe," Dr Pozniak said.

Dr Rockstroh reports financial relationships with Abbott, AbbVie, Gilead, Merck, BMS, Janssen, and ViiV Healthcare. Dr Pozniak reports financial relationships with Merck, ViiV Healthcare, Gilead, BMS, and Janssen.

15th European AIDS Conference. Presented October 22, 2015.


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