New U.K. HIV Guidelines Cover When to Start ART, Treatment as Prevention, Pregnancy

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The British HIV Association (BHIVA) has issued revised guidelines for antiretroviral therapy (ART) for adults and for pregnant women and prevention of mother-to-child HIV prevention. Comments are currently being accepted.

ART for Adults

The draft for adults includes guidance on starting ART in treatment-naive patients, supporting people on treatment, and managing people who experience virological failure. The guidelines also cover special considerations for specific patient populations.

The guidelines are available on the BHIVA website, which features an online form for comments, and published in the January 2012 issue of HIV Medicine. The deadline for feedback is March 5, 2012.

As described in an overview by Aidsmap, the revised guidelines recommend that clinicians should discuss with all HIV positive patients the growing evidence that effective ART reduces the likelihood of HIV transmission to sexual partners. However, evidence to date -- for example, recent findings from study HPTN 052 showing a 96% risk reduction -- mainly concerns heterosexual couples having vaginal sex.

Patients should be informed of the prevention benefits of ART even if they do not yet need treatment for their own health because their CD4 T-cell count has not fallen below 350 cells/mm3.

Unlike the latest U.S. guidelines -- which raised the treatment initiation level to 500 cells/mm3 -- BHIVA kept the 350 cells/mm3 threshold for most patients, though people with certain coinfections and other risk factors (e.g., hepatitis B or C, HIV-related kidney disease or neurocognitive impairment) may benefit from starting sooner.

BHIVA came down in favor of tenofovir/emtricitabine (the drugs in the Truvada combination pill) as the favored dual nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) component of ART. U.S. guidelines also deem tenofovir/emtricitabine as the "preferred" NRTI combo, although the new European AIDS Clinical Society (EACS) guidelines rank tenofovir/emtricitabine and abacavir/lamivudine (the drugs in Epzicom) as equals.

BHIVA and the U.S. panel both demoted abacavir due to concerns about lower effectiveness for people with high viral load and elevated cardiovascular risk; tenofovir, however, has been linked to kidney impairment. All guidelines authorities agree that individual risk factors should be taken into account when selecting antiretroviral drugs.

BHIVA lists drugs in 3 classes as preferred third agents: the NNRTI efavirenz (Sustiva), the boosted protease inhibitors atazanavir (Reyataz) or darunavir (Prezista), and the integrase inhibitor raltegravir (Isentress).

Pregnant Women and Infants

has also issued draft guidelines for the management of HIV in pregnant women and prevention of perinatal transmission.

As described in another Aidsmap summary, a key change is that efavirenz is no longer considered contraindicated for pregnant women or women who wish to become pregnant. Earlier guidelines recommended that pregnant women should avoid efavirenz -- especially during the first trimester -- due to studies suggesting a risk of birth defects in animals, but a rigorous review of published data from human studies did not support this concern.

The panel also said HIV positive women who conceive while on a fully suppressive combination ART regimen do not need to add zidovudine (AZT; Retrovir). Women who do not yet need treatment for their own health should still receive ART, preferably a boosted protease inhibitor regimen, to prevent transmission to the baby.

Vaginal delivery -- rather than Cesarean section -- is generally recommended for HIV positive women with undetectable viral load at the time of labor.

Babies born to women with undetectable viral load should receive preventive zidovudine monotherapy, while those born to untreated mothers or women with detectable HIV should receive triple therapy. BHIVA still recommends that HIV positive mothers should not breastfeed, regardless of treatment status or viral load, though it offers guidance for those who choose to do so.

The draft pregnancy guidelines are also available online, with comments accepted until February 24.

2/21/12

References

British HIV Association (BHIVA). Guidelines for the treatment of HIV-1 infected adults with antiretroviral therapy 2012 - Consultation open. http://www.bhiva.org/TreatmentGuidelinesConsultation.aspx.

British HIV Association (BHIVA). Guidelines for the management of HIV infection in pregnant women 2012 - consultation open. http://www.bhiva.org/PregnancyGuidelinesConsultation.aspx.

Other Sources

K Alcorn. New BHIVA guidelines recommend discussion with all patients on potential of HIV treatment to protect sexual partners. Aidsmap. February 6, 2012.

K Alcorn. UK guidelines on treatment of HIV in pregnancy give green light to efavirenz. Aidsmap. February 17, 2012.