2019 Update of the European AIDS Clinical Society Guidelines for Treatment of People Living With HIV Version 10.0

L Ryom; A Cotter; R De Miguel; C Béguelin; D Podlekareva; JR Arribas; C Marzolini; PGM Mallon; A Rauch; O Kirk; JM Molina; G Guaraldi; A Winston; S Bhagani; P Cinque; JD Kowalska; S Collins; M Battegay

Disclosures

HIV Medicine. 2020;21(10):617-624. 

In This Article

ART Section

In the 2019 version, the layout for initial ART regimens, treatment in pregnancy/women wishing to conceive and in persons coinfected with tuberculosis (TB) were made uniform to ensure consistency.

Before initiating ART, it is recommended to consider if a woman is pregnant or wishes to conceive, and if the person has an opportunistic infection or any potential treatment-limiting comorbidities. In addition, it is recommended to consider if the person is at risk of DDIs or if the person has swallowing difficulties. In all these instances, the Guidelines provide management recommendations.

Among the recommended first-line regimens for ART-naïve PLWH, EACS recommends four preferred options consisting of two nucleoside reverse transcriptase inhibitors [NRTIs; abacavir (ABC)/lamivudine (3TC), tenofovir alafenamide (TAF)/emtricitabine (FTC), tenofovir disoproxil fumarate (TDF)/TFC or TDF/3TC] in combination with an unboosted integrase strand transfer inhibitor [INSTI; dolutegravir (DTG), BIC or raltegravir (RAL)] (Table 1). Among these preferred regiments, EACS favour those with a high genetic barrier (DTG or BIC) as a third agent.

Other recommended first-line regimens include one two-drug combination with an NRTI (3TC) plus an INSTI (DTG), and three three-drug combinations with two NRTIs (TAF/FTC, TDF/FTC or TDF/3TC) plus a nonnucleoside reverse transcriptase inhibitor [NNRTI; DOR or rilpivirine (RPV)] or plus a boosted protease inhibitor [PI/b; cobicistat (COBI)- or ritonavir (RTV)-boosted darunavir (DRV/c or DRV/r)] (Table 1).

The alternative regimen recommendations to be used when none of the preferred regimens are available are shown in Table 1.

The following two-drug combinations are recommended as possible switch strategies; 3TC with DTG, DRV/b or boosted atazanavir (ATV/b) or DTG plus RPV.

Three new tables were included for pregnant women living with HIV or women wishing to conceive to specify which drugs are considered safe and which to avoid. EACS currently recommends not using DTG in women who wish to conceive because of the reported higher risk of neural tube defect if used preconception.[3] As a consequence of insufficient data on safety and efficacy in pregnancy, TAF, RAL once a day (qd), BIC and DOR are currently not recommended in women who become pregnant while on ART. In addition, COBI boosting has proved less robust than RTV boosting during pregnancy, and therefore COBI-boosted elvitegravir (EVG/c) is not recommended and ATV or DRV should be boosted only with RTV in women who become pregnant while on ART. The preferred initial options for ART-naïve pregnant women include combinations of two NRTIs (ABC/3TC, TDF/FTC or TDF/3TC) plus an INSTI [DTG, which can be used after pregnancy week 8, or RAL twice a day (bid)]. The recommended regimens include two NRTIs (TDF/FTC or TDF/3TC) plus a PI/r (DRV/r). Alternative regimens to be considered consist of two NRTIs (ABC/3TC, TDF/FTC or TDF/3TC) plus an NNRTI [efavirenz (EFV) or RPV] or plus a PI/r (ATV/r or DRV/r). A section on labour and breastfeeding was further added.

For PLWH coinfected with susceptible TB, the recommended ART regimens to be used with rifampicin include the combination of two NRTIs (TDF/FTC, TDF/3TC or ABC/3TC) plus an NNRTI (EFV), or for alternative regimens plus an INSTI (DTG bid or RAL bid). An updated table further describes the most relevant DDIs when ART is co-administered with rifampicin or rifabutin.

For post-exposure prophylaxis (PEP), additional regimen combinations with TAF/FTC, RAL qd and BIC were included. For pre-exposure prophylaxis (PrEP), use of daily TAF/FTC was included as a possible alternative in men who have sex with men and transgender women.

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