The International Antiviral Society – USA Panel has issued its 2016 updated recommendations for the use of antiretroviral therapy (ART) in adults aged ≥18 years with established HIV infection. The updated recommendations include when to start treatment, initial regimens, and changing regimens, along with recommendations for using antiretroviral drugs (ARVs) for preventing HIV among those at risk, including preexposure and postexposure prophylaxis. Among the recommendations:

• Initiation of ART is recommended as soon as possible in the setting of acute HIV infection.

• All HIV-infected individuals with detectable plasma virus should receive treatment with recommended initial regimens consisting of an integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs).

• Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals.

Citation: Günthard HF, Saag MS, Benson CA, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults. 2016 recommendations of the International Antiviral Society – USA Panel. JAMA. 2016;316(2):191-210. doi:10.1001/jama.2016.8900.

Commentary: Data from randomized controlled trials now support treatment of all persons with HIV regardless of their CD4 count. Early treatment with combination antiretroviral therapy (ART) has been shown to significantly decrease HIV-related morbidity and mortality. Moreover, there is growing evidence that persons taking suppressive therapy do not transmit HIV to contacts. Effective treatment can also be viewed as effective HIV prevention. The majority of first-line therapies, specifically the InSTI-based products, can be taken as one pill per day, greatly improving adherence. The tolerability of these agents is very good and issues of toxicity and drug resistance are uncommon. Also noted in this study is the use of ART, specifically the combination of tenofovir/emtricitabine taken daily for HIV prevention as preexposure prophylaxis or PrEP. Primary care clinicians who do not see themselves as HIV specialists can play a key role in prescribing PrEP, and the CDC has a set protocol for guidance. Lastly, the IAS guidelines addresses the prompt use of combination ART taken for 28 days as post-exposure prophylaxis following occupational (needle stick or mucous membrane) or non-occupational exposure (sexual or injection drug use), which all clinicians should be familiar with. —Jeffrey T. Kirchner, DO, FAAFP, AAHIVS