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Special Communication
July 24/31, 2018

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the International Antiviral Society–USA Panel

Author Affiliations
  • 1University of Alabama at Birmingham
  • 2University of California San Diego School of Medicine
  • 3Massachusetts General Hospital and Harvard Medical School, Boston
  • 4The Alfred Hospital and Monash University, Melbourne, Australia
  • 5University of California Los Angeles
  • 6Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
  • 7University of California San Diego, La Jolla
  • 8AIDS Research Consortium of Atlanta, Atlanta, Georgia
  • 9San Francisco Department of Public Health and University of California San Francisco
  • 10Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
  • 11University of North Carolina at Chapel Hill School of Medicine
  • 12University Hospital of Cologne, Department I of Internal Medicine, Cologne, Germany, and German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
  • 13University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
  • 14University of Paris Diderot and Saint-Louis Hospital, APHP, Paris
  • 15International Antiviral Society–USA, San Francisco, California
  • 16University of California San Francisco
JAMA. 2018;320(4):379-396. doi:10.1001/jama.2018.8431

Importance  Antiretroviral therapy (ART) is the cornerstone of prevention and management of HIV infection.

Objective  To evaluate new data and treatments and incorporate this information into updated recommendations for initiating therapy, monitoring individuals starting therapy, changing regimens, and preventing HIV infection for individuals at risk.

Evidence Review  New evidence collected since the International Antiviral Society–USA 2016 recommendations via monthly PubMed and EMBASE literature searches up to April 2018; data presented at peer-reviewed scientific conferences. A volunteer panel of experts in HIV research and patient care considered these data and updated previous recommendations.

Findings  ART is recommended for virtually all HIV-infected individuals, as soon as possible after HIV diagnosis. Immediate initiation (eg, rapid start), if clinically appropriate, requires adequate staffing, specialized services, and careful selection of medical therapy. An integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) is generally recommended for initial therapy, with unique patient circumstances (eg, concomitant diseases and conditions, potential for pregnancy, cost) guiding the treatment choice. CD4 cell count, HIV RNA level, genotype, and other laboratory tests for general health and co-infections are recommended at specified points before and during ART. If a regimen switch is indicated, treatment history, tolerability, adherence, and drug resistance history should first be assessed; 2 or 3 active drugs are recommended for a new regimen. HIV testing is recommended at least once for anyone who has ever been sexually active and more often for individuals at ongoing risk for infection. Preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine and appropriate monitoring is recommended for individuals at risk for HIV.

Conclusions and Relevance  Advances in HIV prevention and treatment with antiretroviral drugs continue to improve clinical management and outcomes for individuals at risk for and living with HIV.

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