User login
For adult patients with HIV, earlier treatment results in faster and more likely virologic suppression along with greater linkage to care, according to the 2018 Recommendations of the International Antiviral Society-USA (IAS-USA).
The updated treatment and prevention guidelines also have outlined drug selection, including three-drug therapy (usually as a single-tablet combination) and two-drug switch therapy, as well as discouragement of cash incentives for treatment. The guidelines, written by Michael S. Saag, MD, of the University of Alabama at Birmingham and his coauthors, were published in JAMA.
Since the previous IAS-USA guidelines were published in 2016 (JAMA. 2016;316(2):191-210), multiple studies have investigated the importance of timely antiretroviral therapy (ART). In one study, patients with HIV began ART within 24 hours of diagnosis. These patients achieved virologic suppression (fewer than 200 HIV RNA copies/mL) quicker than patients treated according to previous guidelines (medians, 1.8 months vs. 4.3 months; P = .0001). Another study found that patients who began ART immediately were more likely to achieve viral suppression at 12 months (50% vs. 34%; P = .007) and become linked to care at 3 months (68% vs. 43%). As such, the updated guidelines recommended that ART should be started as soon as possible (even without supporting laboratory results). Exceptions were maintained for patients not ready to start therapy and those at risk for immune reconstitution syndrome.
With regard to initial treatment selection, three-drug therapy is recommended, incorporating an integrase single-strand transfer inhibitor (InSTI) with 2 nucleoside reverse transcriptase inhibitors.
Single-tablet formulations are effective, well tolerated, and promote medication adherence. Dolutegravir is not recommended in women who are pregnant or may become pregnant because it may increase the risk of neural tube defects. It is unclear whether other InSTIs pose similar risks. Although two-drug regimens are not recommended for initial therapy, they may be considered as switch therapy to reduce cost and complications.
The 2018 guidelines have discouraged cash incentives for ART adherence because such programs have proven ineffective. Conversely, noncash incentives are likely to be beneficial. Further recommendations to improve outcomes were wide ranging and included identification of patients subject to food scarcity or psychiatric disorders. For the latter, chronic depression has been associated with worse outcomes – including a two-fold mortality risk – and so appropriate treatment is recommended.
The researchers concluded with a brief review of future directions for HIV treatment and prevention. Long-acting injectable and oral antiretrovirals are under investigation, along with implantable and nanoparticle therapies.
“Clinicians who care for patients with HIV have a major role in advocating for programs and their patients at the local, national, and international levels,” the authors wrote. “Advocacy should go beyond access to ART and include access to mental health and substance abuse services, as well as efforts to end policies such as HIV criminalization that impede the ability to provide evidence-based care and prevention services.”
The authors reported support from Gilead, ViiV, Merck, and other sources. The current guidelines were funded by IAS-USA.
SOURCE: Saag MS et al. JAMA. 2018;320[4]:379-96.
New antiretroviral regimens, coupled with an improved understanding of HIV biology, have “led to improved treatment strategies and a significant decrease in mortality, transforming AIDS into a chronic, manageable disease in many countries of the world,” James Riddell IV, MD, wrote in an editorial in JAMA.
Recent research highlights the importance of early treatment with antiretroviral therapy. Patients treated as soon as possible are more likely to achieve viral suppression sooner and are more likely to be linked to care. Viral suppression not only improves patient quality of life but also prevents viral transmission.
Dr. Riddell praised the role of guidelines in raising quality of care for a broad range of patients but cautioned that “guidelines serve only as a starting point, as evidenced by the fact that implementation has proved to be much more challenging.”
Even as diagnostic and treatment abilities have advanced, a 2014 study showed that “only 49% of the approximately 1.1 million people living with HIV in the United States were virologically suppressed. Therefore, it is clear that new strategies are needed to reach HIV-infected individuals who are not receiving effective treatment.” To tackle the HIV epidemic, Dr. Riddell called for “a multipronged approach …that includes new HIV prevention strategies (HIV preexposure prophylaxis, education regarding condom use), expanded HIV testing, rapid and immediate linkage to care when possible, viral suppression for persons who are HIV infected, and strategies to enhance adherence to therapy and retention in care.”
James Riddell IV, MD, is with the division of infectious diseases in the department of internal medicine at the University of Michigan Medical Center. These comments are adapted from an editorial (JAMA 2018;320[4]:347-9).
New antiretroviral regimens, coupled with an improved understanding of HIV biology, have “led to improved treatment strategies and a significant decrease in mortality, transforming AIDS into a chronic, manageable disease in many countries of the world,” James Riddell IV, MD, wrote in an editorial in JAMA.
Recent research highlights the importance of early treatment with antiretroviral therapy. Patients treated as soon as possible are more likely to achieve viral suppression sooner and are more likely to be linked to care. Viral suppression not only improves patient quality of life but also prevents viral transmission.
Dr. Riddell praised the role of guidelines in raising quality of care for a broad range of patients but cautioned that “guidelines serve only as a starting point, as evidenced by the fact that implementation has proved to be much more challenging.”
Even as diagnostic and treatment abilities have advanced, a 2014 study showed that “only 49% of the approximately 1.1 million people living with HIV in the United States were virologically suppressed. Therefore, it is clear that new strategies are needed to reach HIV-infected individuals who are not receiving effective treatment.” To tackle the HIV epidemic, Dr. Riddell called for “a multipronged approach …that includes new HIV prevention strategies (HIV preexposure prophylaxis, education regarding condom use), expanded HIV testing, rapid and immediate linkage to care when possible, viral suppression for persons who are HIV infected, and strategies to enhance adherence to therapy and retention in care.”
James Riddell IV, MD, is with the division of infectious diseases in the department of internal medicine at the University of Michigan Medical Center. These comments are adapted from an editorial (JAMA 2018;320[4]:347-9).
New antiretroviral regimens, coupled with an improved understanding of HIV biology, have “led to improved treatment strategies and a significant decrease in mortality, transforming AIDS into a chronic, manageable disease in many countries of the world,” James Riddell IV, MD, wrote in an editorial in JAMA.
Recent research highlights the importance of early treatment with antiretroviral therapy. Patients treated as soon as possible are more likely to achieve viral suppression sooner and are more likely to be linked to care. Viral suppression not only improves patient quality of life but also prevents viral transmission.
Dr. Riddell praised the role of guidelines in raising quality of care for a broad range of patients but cautioned that “guidelines serve only as a starting point, as evidenced by the fact that implementation has proved to be much more challenging.”
Even as diagnostic and treatment abilities have advanced, a 2014 study showed that “only 49% of the approximately 1.1 million people living with HIV in the United States were virologically suppressed. Therefore, it is clear that new strategies are needed to reach HIV-infected individuals who are not receiving effective treatment.” To tackle the HIV epidemic, Dr. Riddell called for “a multipronged approach …that includes new HIV prevention strategies (HIV preexposure prophylaxis, education regarding condom use), expanded HIV testing, rapid and immediate linkage to care when possible, viral suppression for persons who are HIV infected, and strategies to enhance adherence to therapy and retention in care.”
James Riddell IV, MD, is with the division of infectious diseases in the department of internal medicine at the University of Michigan Medical Center. These comments are adapted from an editorial (JAMA 2018;320[4]:347-9).
For adult patients with HIV, earlier treatment results in faster and more likely virologic suppression along with greater linkage to care, according to the 2018 Recommendations of the International Antiviral Society-USA (IAS-USA).
The updated treatment and prevention guidelines also have outlined drug selection, including three-drug therapy (usually as a single-tablet combination) and two-drug switch therapy, as well as discouragement of cash incentives for treatment. The guidelines, written by Michael S. Saag, MD, of the University of Alabama at Birmingham and his coauthors, were published in JAMA.
Since the previous IAS-USA guidelines were published in 2016 (JAMA. 2016;316(2):191-210), multiple studies have investigated the importance of timely antiretroviral therapy (ART). In one study, patients with HIV began ART within 24 hours of diagnosis. These patients achieved virologic suppression (fewer than 200 HIV RNA copies/mL) quicker than patients treated according to previous guidelines (medians, 1.8 months vs. 4.3 months; P = .0001). Another study found that patients who began ART immediately were more likely to achieve viral suppression at 12 months (50% vs. 34%; P = .007) and become linked to care at 3 months (68% vs. 43%). As such, the updated guidelines recommended that ART should be started as soon as possible (even without supporting laboratory results). Exceptions were maintained for patients not ready to start therapy and those at risk for immune reconstitution syndrome.
With regard to initial treatment selection, three-drug therapy is recommended, incorporating an integrase single-strand transfer inhibitor (InSTI) with 2 nucleoside reverse transcriptase inhibitors.
Single-tablet formulations are effective, well tolerated, and promote medication adherence. Dolutegravir is not recommended in women who are pregnant or may become pregnant because it may increase the risk of neural tube defects. It is unclear whether other InSTIs pose similar risks. Although two-drug regimens are not recommended for initial therapy, they may be considered as switch therapy to reduce cost and complications.
The 2018 guidelines have discouraged cash incentives for ART adherence because such programs have proven ineffective. Conversely, noncash incentives are likely to be beneficial. Further recommendations to improve outcomes were wide ranging and included identification of patients subject to food scarcity or psychiatric disorders. For the latter, chronic depression has been associated with worse outcomes – including a two-fold mortality risk – and so appropriate treatment is recommended.
The researchers concluded with a brief review of future directions for HIV treatment and prevention. Long-acting injectable and oral antiretrovirals are under investigation, along with implantable and nanoparticle therapies.
“Clinicians who care for patients with HIV have a major role in advocating for programs and their patients at the local, national, and international levels,” the authors wrote. “Advocacy should go beyond access to ART and include access to mental health and substance abuse services, as well as efforts to end policies such as HIV criminalization that impede the ability to provide evidence-based care and prevention services.”
The authors reported support from Gilead, ViiV, Merck, and other sources. The current guidelines were funded by IAS-USA.
SOURCE: Saag MS et al. JAMA. 2018;320[4]:379-96.
For adult patients with HIV, earlier treatment results in faster and more likely virologic suppression along with greater linkage to care, according to the 2018 Recommendations of the International Antiviral Society-USA (IAS-USA).
The updated treatment and prevention guidelines also have outlined drug selection, including three-drug therapy (usually as a single-tablet combination) and two-drug switch therapy, as well as discouragement of cash incentives for treatment. The guidelines, written by Michael S. Saag, MD, of the University of Alabama at Birmingham and his coauthors, were published in JAMA.
Since the previous IAS-USA guidelines were published in 2016 (JAMA. 2016;316(2):191-210), multiple studies have investigated the importance of timely antiretroviral therapy (ART). In one study, patients with HIV began ART within 24 hours of diagnosis. These patients achieved virologic suppression (fewer than 200 HIV RNA copies/mL) quicker than patients treated according to previous guidelines (medians, 1.8 months vs. 4.3 months; P = .0001). Another study found that patients who began ART immediately were more likely to achieve viral suppression at 12 months (50% vs. 34%; P = .007) and become linked to care at 3 months (68% vs. 43%). As such, the updated guidelines recommended that ART should be started as soon as possible (even without supporting laboratory results). Exceptions were maintained for patients not ready to start therapy and those at risk for immune reconstitution syndrome.
With regard to initial treatment selection, three-drug therapy is recommended, incorporating an integrase single-strand transfer inhibitor (InSTI) with 2 nucleoside reverse transcriptase inhibitors.
Single-tablet formulations are effective, well tolerated, and promote medication adherence. Dolutegravir is not recommended in women who are pregnant or may become pregnant because it may increase the risk of neural tube defects. It is unclear whether other InSTIs pose similar risks. Although two-drug regimens are not recommended for initial therapy, they may be considered as switch therapy to reduce cost and complications.
The 2018 guidelines have discouraged cash incentives for ART adherence because such programs have proven ineffective. Conversely, noncash incentives are likely to be beneficial. Further recommendations to improve outcomes were wide ranging and included identification of patients subject to food scarcity or psychiatric disorders. For the latter, chronic depression has been associated with worse outcomes – including a two-fold mortality risk – and so appropriate treatment is recommended.
The researchers concluded with a brief review of future directions for HIV treatment and prevention. Long-acting injectable and oral antiretrovirals are under investigation, along with implantable and nanoparticle therapies.
“Clinicians who care for patients with HIV have a major role in advocating for programs and their patients at the local, national, and international levels,” the authors wrote. “Advocacy should go beyond access to ART and include access to mental health and substance abuse services, as well as efforts to end policies such as HIV criminalization that impede the ability to provide evidence-based care and prevention services.”
The authors reported support from Gilead, ViiV, Merck, and other sources. The current guidelines were funded by IAS-USA.
SOURCE: Saag MS et al. JAMA. 2018;320[4]:379-96.
FROM JAMA
Key clinical point: For patients with HIV, earlier treatment results in faster virologic suppression.
Major finding: Patients with HIV who started antiretroviral therapy within 24 hours of HIV diagnosis achieved virologic suppression ( 200 HIV RNA copies/mL) in a median time of 1.8 months, compared with 4.3 months for those treated in accordance with previous recommendations (P = .0001).
Study details: 2018 HIV treatment and prevention guidelines by the International Antiviral Society-USA Panel; based on numerous studies.
Disclosures: The authors reported funding from Gilead, ViiV, Merck, and others. The guidelines were sponsored by the International Antiviral Society-USA (IAS-USA).
Source: Saag et al. JAMA. 2018:320(4);379-96.