Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV
The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.
What's New in the Guidelines?
Last Updated: July 10, 2019; Last Reviewed: July 10, 2019
This guideline update focuses on three sections: (1) Transgender People with HIV, a new section in the guidelines; (2) Substance Use Disorders and HIV, a completely rewritten section that was formerly called HIV and People Who Use Illicit Drugs; and (3) HIV-2 Infection. Revisions to other sections of the guidelines are expected to be released in late 2019.
Transgender People with HIV
Transgender and nonbinary people bear a disproportionate burden of HIV. According to the most recent estimate, 14% of transgender women have HIV and 2% of transgender men have HIV. To address the specific HIV care needs of these individuals, the Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) has created a new section of the guidelines. This section focuses on:
- The importance of providing HIV care services within a gender-affirmative care model to reduce potential barriers to antiretroviral therapy (ART) adherence and maximize the likelihood of achieving sustained viral suppression;
- The role of gender-affirming hormonal therapy and the potential interactions between these drugs and certain antiretroviral (ARV) drugs; and
- Potential health impacts of gender-affirming hormonal therapy on transgender persons with HIV.
Substance Use Disorders and HIV
The Panel notes that substance use disorders (SUDs) are prevalent among people with HIV and contribute to poor health outcomes; therefore, screening for SUDs should be a routine part of clinical care.
This newly expanded section now includes information on the following substances: alcohol, benzodiazepines, cannabinoids, club drugs, opioids, stimulants (cocaine and methamphetamines), and tobacco. The discussions focus on the potential health consequences of each substance for persons with HIV, the role of providers in managing patients with SUDs, the impact of SUDs on the HIV continuum of care and ART, and treatment options for these SUDs.
This section has been revised to focus on when to start ART and which ARV regimens to use in persons with HIV-2 monoinfection or HIV-1/HIV-2 coinfection. The key revisions are as follows:
- Previously, the Panel recommended starting ART in persons with HIV-2 before clinical progression. Existing data on the treatment of HIV-2, and extrapolation from data on the treatment of HIV-1, suggest that ART should be started at or soon after HIV-2 diagnosis to prevent disease progression and transmission of HIV-2 to others (AIII).
- No randomized controlled clinical trials have determined which ARV regimens are the most effective for treating HIV-2. However, since the last revision, two single-arm clinical trials have shown favorable outcomes in patients receiving integrase strand transfer inhibitor (INSTI)-based regimens (AII). On the basis of these study results, the Panel recommends using an INSTI-based regimen as an initial ART regimen for treatment-naive patients with HIV-2. A regimen that includes a boosted protease inhibitor that is active against HIV-2 (darunavir or lopinavir) can be used as an alternative (BII).