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

Comorbidity Section

The comorbidity section continues to be the largest section of the EACS Guidelines and provides screening and management recommendations for the most common comorbid conditions among PLWH and for conditions that require specific guidance.

Given the increased prevalence of frailty in PLWH, a new table outlines definitions, recommended assessments and management to help identify those at frailty risk. For some comorbidities [e.g. hypertension, nonalcoholic fatty liver disease (NAFLD) and bone disease], different age-specific guidance for diagnosis [e.g. using dual-energy X-ray absorptiometry (DEXA) scan and liver fibrosis scores] and management (e.g. for hypertension) is provided.

Recommendations to lower blood pressure targets to systolic pressure < 130 mmHg and diastolic pressure < 80 mmHg were previously introduced (v9.0) for high-risk individuals; in 2019 (v10.0), these recommendations were further broadened to apply to all PLWH. Furthermore, antihypertensive drug sequencing was amended.

The threshold for ART modification in relation to 10-year predicted cardiovascular disease (CVD) risk has been lowered from 20% to 10%. Similarly, lipid targets have been lowered for both primary and secondary prophylaxis.

As obesity and weight increase have become more frequent in PLWH, and this is a rapidly evolving field, an addition on diagnosis, risk factors and management of obesity was made to the existing chapter on lipoatrophy. New data on weight increase related to use of INSTIs and TAF were added to the table on potential adverse drug effects.

In the liver section, a fourth step was added to the work-up of persons with increased transaminases to include risk stratification using aspartate aminotrabsferase to platelet ratio (APRI), fibrosis-4 (FIB4), NAFLD fibrosis score and transient elastography. Similarly, the screening recommendation for hepatocellular carcinoma in noncirrhotic persons with chronic HBV coinfection was amended in collaboration with the viral hepatitis panel to include an age threshold acknowledging the higher risk in those older than 45 years.[4] The algorithm for surveillance for varices and primary prophylaxis was updated to incorporate transient elastography (where available) with platelet counts to determine indications for upper gastrointestinal endoscopy. Finally, the diagnostics flow-chart for NAFLD was revised to include the use of fibrosis scores.

Finally, in the renal subsection, it was specified to use urine albumin to creatinine ratio to screen for glomerular disease (such as diabetes and HIV-related disease), and urine protein to creatinine ratio to screen for tubular diseases (i.e. ART drug toxicity). The cut-off values for albuminuria and proteinuria have further been streamlined with the Kidney Disease: Improving Global Outcomes (KDIGO) recommendations.[5]

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