Updates to the Antiretroviral Agents in Adults and Adolescents Living with HIV Guidelines Released

Date: June 3, 2021

Several sections of the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV have been updated. Key changes made by the Panel include:

What to Start

  • The Panel now recommends that a dolutegravir (DTG) based regimen can be prescribed for most people with HIV who are of childbearing potential.
  • Raltegravir-based regimens as initial antiretroviral therapy (ART) have been moved from the category of “Recommended Initial Regimens for Most People with HIV” to “Recommended Initial Regimen in Certain Clinical Situations”.

Virologic Failure

  • For patients with virologic failure, the Panel’s recommendation of “A new regimen should include at least two, and preferably three, fully active agents” has been changed to “A new regimen can include two fully active drugs if at least one with a high resistance barrier is included (e.g., DTG or boosted darunavir).”

Poor CD4 Recovery and Persistent Inflammation

  • This section has been revised to include updates on studies describing mechanisms for declining CD4 counts despite suppressive ART and a review of the status of experimental interventional strategies to reduce persistent inflammation. It also includes an explanation for why monitoring levels of inflammation is not currently recommended in clinical practice.

Optimizing Antiretroviral Therapy in the Setting of Viral Suppression

  • The update to this section primarily focuses on the role of the new long-acting injectable regimen of intramuscular cabotegravir (CAB) plus rilpivirine (RPV) in this setting. The section describes the clinical trial data to date on long-acting CAB plus RPV, practical considerations when using these agents, and management recommendations in the event of missed doses.

Adolescents and Young Adults with HIV

  • This section has been revised extensively to include current epidemiologic data on HIV in adolescents and young adults (AYA) in the United States, unique challenges faced by this population compared to their adult counterparts, the importance of assisting AYA in navigating optimal transition from pediatric to adult clinical care setting.

Women with HIV

  • This section has been updated to include a review of the literature on weight gain in women after initiation or switch of ART.
  • Updated data describing the prevalence of neural tube defects in infants born to women who were receiving either DTG or efavirenz during conception have been added.
  • Information regarding hormonal therapy and antiretroviral (ARV) drug interactions has been updated.
  • A new subsection offering considerations regarding menopause in women with HIV and its potential impact on ART is included.

Substance Use Disorder and HIV

  • A subsection has been added to this section discussing the factors to consider when contemplating the use of long-acting injectable CAB plus RPV in people with substance use disorder and HIV.

Tuberculosis/HIV Coinfection

  • The key update to this section includes recommendations for ARV regimens that can be used if a 3-month regimen of weekly isoniazid and rifapentine is prescribed for the treatment of latent tuberculosis infection.

Cost Considerations and Antiretroviral Therapy

  • This section includes a new discussion on the costs and cost-effectiveness of newer ARV agents, such as ibalizumab, when used as part of ART for persons with multiple-drug-resistant HIV.
  • A new subsection on the cost and cost-effectiveness of comprehensive HIV care has been added.

Drug-Drug Interaction Tables

  • The drug-drug interaction tables have been updated with new information on interactions between CAB, RPV (intramuscular), and fostemsavir.

For a complete list of updates, please see What's New in the Guidelines. Additions and revisions are highlighted in yellow throughout the PDF version of the guidelines. To view or download the guidelines, go to the Adult and Adolescent Antiretroviral Agent section of Clinical Info’s website. The guideline tables and recommendations can also be downloaded as separate PDF files. Clinical Info Welcomes Your Feedback. Feedback on the latest revisions to the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV is welcome. Please send your comments with the subject line “Antiretroviral Agents in Adults and Adolescents Living with HIV Guidelines” to ContactUs@HIVinfo.NIH.gov by June 21, 2021.