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DHHS Updates Antiretroviral Treatment Guidelines for Adults and Children

The U.S. Department of Health and Human Services (DHHS) has released updated versions of its antiretroviral treatment guidelines for adults and adolescents, and for children with HIV. The new adult guidelines include revised recommendations for first-line antiretroviral therapy (ART) as well as management of treatment-experienced patients. The revised pediatric guidelines include a discussion of very early treatment for HIV-infected infants.

Adults and Adolescents

The revised Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents feature the following key updates, which are summarized in a What's New in the Guidelines section and highlighted in yellow throughout the text and tables.

What to Start

• Changes to the list of Recommended, Alternative, and Other regimens for treatment-naive patients.
• New table to assist clinicians in selecting an initial antiretroviral regimen based on specific clinical scenarios and antiretroviral-related considerations.
• There are now 5 Recommended first-line regimens, including 4 integrase inhibitor combinations and 1 boosted protease inhibitor combination (darunavir/ritonavir, or Prezista).
• Atazanavir/ritonavir (Reyataz) and efavirenz (Sustiva) regimens previously classified as Recommended have been moved to the Alternative category due to toxicities.

Treatment-Experienced Patients

• Expanded information on management of patients failing first-line and second-line ART regimens.
• New section on central nervous system (CNS) virological failure and new-onset neurological symptoms.
• New section on poor CD4 T-cell recovery and persistent inflammation and immune activation, and their role in increased risk of AIDS-related and non-AIDS morbidity.

Acute/Early HIV Infection

• Updated section to include 2014 Centers for Disease Control and Prevention (CDC) recommendation for diagnosis of HIV infection, including in people with acute/early infection.

Antiretroviral Drug Interactions

• New table outlining mechanisms of antiretroviral drug interactions.
• Updates to all drug interaction tables, particularly to those related to ritonavir- or cobicistat-boosted antiretrovirals.

HIV/HCV Coinfection

• Updated information on use of different antiretroviral drugs with the recently approved AbbVie Viekira Pak (paritaprevir/ritonavir/ombitasvir + dasabuvir) hepatitis C regimen.

Pediatric Guidelines

The updates Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection include the following updates, also summarized in a What's New in the Guidelines section and highlighted in yellow throughout the text and tables.

• New information on diagnosis of HIV infection and clinical and laboratory monitoring of pediatric HIV patients.
• Updated recommendations for when to start ART, now based CD4 T-cell count rather than CD4 percentage.
• New recommendations for urgent ART initiation, including for all children younger than 12 months and for older children with opportunistic illnesses or low CD4 count.
• Addition of integrase inhibitor-based regimens for children.
• New section on ART for newborns, including rapid diagnosis and the potential benefits and risks of early intensive treatment.  
• Summary of available information about antiretroviral dosing and safety in full-term and pre-term infants.  
• Updated toxicity tables including recent data on CNS adverse effects of efavirenz and newer antiretrovirals' effects on creatinine determination.
• New recommendations about modifying or switching ART regimens in children with sustained viral suppression to improve simplicity, convenience, or safety.

4/10/15

References

HHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Updated April 8, 2015.

DHHS Panel on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Updated March 5, 2015.