By Rebecca Bowers

EXECUTIVE SUMMARY

Clinicians involved in preventing and treating HIV will want to update their knowledge base with recommendations from the International Antiviral Society–USA for the use of antiretroviral drugs.

  • The updated recommendations, issued by a volunteer panel of HIV research and patient care experts, offer guidance on the use of antiretroviral drugs, including how to initiate therapy, monitor individuals starting regimens, and how to change drug treatment. Information includes how to prevent HIV infection in individuals at risk.
  • While researchers continue to search for a cure, scientists also are looking to achieve sustained, antiretroviral drug therapy-free remission of HIV.

Clinicians involved in preventing and treating HIV will want to update their knowledge base with recommendations from the International Antiviral Society–USA for the use of antiretroviral drugs.1

The updated recommendations, issued by a volunteer panel of HIV research and patient care experts, offer guidance on the use of antiretroviral drugs, including how to initiate therapy, monitor individuals starting regimens, and how to change drug treatment. Information also includes how to prevent HIV infection in individuals at risk.

The new recommendations, which update information issued since 2016, reflect the joint commitment of researchers who are working together to improve clinical outcomes and treatments, says Michael Saag, MD, a professor of medicine at the University of Alabama at Birmingham’s Division of Infectious Diseases and director of the university’s Center for AIDS Research. Saag served as lead author of the current guidance.

“We know that antiretroviral therapy is the cornerstone of prevention and management of HIV infection, but it’s critical to continually evaluate new data and treatments for initiating therapy, monitoring individuals starting therapy, changing regimens and preventing HIV infection for those at risk, reaffirming the standard of providing the utmost treatment and care possible,” said Saag in a press statement.

What Are the Highlights?

Much has changed in the HIV prevention and treatment world since the society issued its first guidance in 1996. Highlights of the current recommendation include:

  • Clinicians should update initial regimens, focusing primarily on unboosted integrase strand transfer inhibitor regimens. Rapid initiation of antiretroviral therapy is encouraged, including same-day initiation if possible.
  • Routine use of Mycobacterium avium complex prophylaxis for those with advanced disease for antiretroviral therapy who are on effective therapy is not recommended.
  • Discontinue use of routine CD4 count lab testing once a patient has sustained undetectable HIV RNA levels for a year and has a CD4 count above 250 cells/µl.
  • One option for preexposure prophylaxis for those who are uninfected with HIV but remain at risk for infection is to include an episode-based approach, whereby patients can take preventive antiretroviral pills prior to exposure, with a follow-up pill once daily for two days post-exposure.1

“HIV care continues to evolve, and clinicians and their patients benefit from applying the latest knowledge to keep pace with the many ways this has changed,” said study co-author Paul Volberding, MD, a professor at the University of California San Francisco. “The latest IAS-USA guidelines continue a tradition of providing a concise and current set of recommendations, and we are proud of how these have captured the directions in our field of medicine.”

A multipronged approach is necessary to address the HIV epidemic effectively, noted James Riddell, IV, MD, a professor of internal medicine at the University of Michigan, in an accompanying commentary. These approaches should include HIV preexposure prophylaxis, condom use education, expanded testing for HIV, rapid and immediate linkage to care, achievement of viral suppression in those infected with the disease, and ways to improve therapy compliance and continuation of care.2

Future Advancements Await

While researchers continue to search for an HIV cure, scientists also are looking to achieve sustained antiretroviral drug therapy-free remission. In this approach, the objective is not to eradicate all of the virus-carrying cells in the body, which are known as the HIV reservoirs. Rather, sustained remission would allow a person living with HIV to maintain suppression of the latent virus without using daily medication.

One scientific approach in remission therapy relies on intermittent or continual non-antiretroviral drug interventions. Another method involves stimulating the immune system to independently have long-lasting control over HIV. Broadly neutralizing HIV antibodies now in research are offering potential solutions for intermittent or continual interventions for long-lasting remission free from antiretroviral therapy.3,4 Research in animals and humans is ongoing to find out if periodically receiving infusions or injections of such antibodies can prevent someone from acquiring the virus, as well as suppress it in people who are living with the disease.

In another approach, researchers are analyzing broadly neutralizing HIV antibodies in stimulating the immune system. In early research, scientists at the National Institute of Allergy and Infectious Diseases and Rockefeller University demonstrated that when monkeys infected with a simian form of HIV received infusions of two different types of antibodies, the immune systems of some of the animals were able to control the virus long after the antibodies had dissipated.5

REFERENCES

  1. Saag MS, Benson CA, Gandhi RT, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2018 recommendations of the International Antiviral Society-USA Panel. JAMA 2018;320:379-396.
  2. Riddell J 4th. 2018 IAS-USA recommendations for the use of antiretroviral therapy for HIV: Building on decades of progress. JAMA 2018; 320:347-349.
  3. McCoy LE, Burton DR. Identification and specificity of broadly neutralizing antibodies against HIV. Immunol Rev 2017;275:11-20.
  4. Caskey M, Klein F, Lorenzi JC, et al. Viraemia suppressed in HIV-1-infected humans by broadly neutralizing antibody 3BNC117. Nature 2015;522:487-491.
  5. Nishimura Y, Gautam R, Chun TW, et al. Early antibody therapy can induce long-lasting immunity to SHIV. Nature 2017;543:559-563.