New HIV care recommendations

Therapeutic options for people living with HIV and those exposed to HIV have evolved in recent years, opening up new treatment prospects. But the infection is still active in France, and there are still too many late diagnoses.

Against this background, HAS, ANRS MIE and CNS are publishing updated recommendations to help professionals offer the best possible therapeutic management of HIV infection.

They include:

new pre- and post-exposure preventive treatments
gynaeco-obstetric and paediatric aspects
specific aspects of antiretroviral treatment
and infectious complications associated with HIV infection.

They are intended for all healthcare professionals (infectious disease specialists, internists, general practitioners, virologists, etc.) involved in supporting people living with HIV, as well as for people living with HIV, people at risk, users and associations working in this field.

HAS: French National Authority for Health (Haute Autorité de santé); ANRS MIE: French Agency for Research on AIDS and Viral Hepatitis Emerging infectious diseases (Agence nationale de recherches sur le VIH/sida, les hépatites virales, la tuberculose, les infections sexuellement transmissibles et les maladies infectieuses émergentes); CNS: French National AIDS Council (Conseil national du sida et des hépatites virales)

HIV: still an active infection in France and still too many late diagnoses

The epidemic is still active in France. Despite the success of antiretroviral drugs, advanced immunodepression at the AIDS stage and its complications have not disappeared. A significant proportion (nearly 25%) of HIV infections are still diagnosed at an advanced stage due to a lack of screening. Targeted and repeated prevention as well as screening campaigns should be stepped up in the populations most at risk, while continuing with systematic screening of the general population, at least once in their lives when having a health check.

HIV prevention means helping people at risk of infection to access at least one effective tool from a range of proven prevention methods (known as ‘diversified prevention’), such as condoms, PrEP (pre-exposure prophylaxis), PEP (post-exposure treatment), etc

New pre- and post-exposure prophylaxis

HIV Pre-exposure prophylaxis (PrEP)

It is highly effective and should be offered to people at risk of infection. These new recommendations underline the need to extend PrEP beyond multi-partner men who have sex with men (MSM) (who currently account for almost all prescriptions) to all situations deemed to put people at risk of exposure to HIV, regardless of their gender or sexual orientation.

Tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) is the first line regimen for PrEP. It can be prescribed even to pregnant or breastfeeding women, or those on hormonal contraception. Injectable cabotegravir-LP will make it possible to offer solutions in cases where PrEP with TDF/FTC is contraindicated, or when oral PrEP cannot be used properly.

HIV post-exposure prophylaxis (PEP)

For PEP, the combination of tenofovir disoproxil fumarate (TDF), lamivudine (3TC) and doravirine is now offered as first-line treatment. This combination was preferred to the previously recommended treatment based on rilpivirine because of the low frequency of viruses resistant to this combination in primary infection in France, and its good overall safety.

After a possible exposure to HIV, a combination of PEP and PrEP is recommended.

Pregnancy, breastfeeding and HIV: what treatments are available?

For pregnant women with HIV, long-term antiretroviral treatment is essential for preserving their own health and preventing perinatal and sexual HIV transmission. Optimal virological control in the mother eliminates the risk of HIV transmission to the child during pregnancy and childbirth. Given its virological efficacy and reassuring data on the low risk of neural tube defects, antiretroviral dolutegravir can be an alterantive to raltegravir or darunavir at any stage of pregnancy.

Provided virological control is optimal, breastfeeding is now possible for women who wish to do so. It is also possible to extend antiviral prophylaxis in breastfed infants to reduce the risk of residual transmission.

Specific features of antiretroviral treatment in adults

Initiation of initial antiretroviral therapy (ART)

Early initiation of ART for people living with HIV (PLHIV) is of major benefit in reducing HIV-related morbidity and mortality, preventing HIV transmission and improving or maintaining quality of life. As a general rule, therapy should be started within 14 days of the initial diagnosis of HIV infection. However, depending on the circumstances, it may be started immediately, particularly in cases of primary infection or when HIV infection is discovered during pregnancy in the^3rd trimester. Or, conversely, it may be deferred, for example in cases of immune deficiency justifying prior investigation for certain opportunistic infections (tuberculosis, cryptococcosis, etc.).

If possible, ART should be initiated with a single daily tablet, providing not only dosing convenience but helping optimise adherence.

Recommendations on the management of infectious complications of HIV infection are incorporated into a specific recommendation.

Changes in therapy in the event of virological control

Once virological control has been achieved, change of ART may be useful or necessary in certain situations and with variable objectives. Usually, the aim is to individualise the optimal combination to improve tolerability or simplify administration, while maintaining immunovirological efficacy, without compromising the efficacy of any subsequent treatment. For example, a change in ART may be proposed to improve and preserve the patient’s quality of life (by correcting side effects or reducing the number of doses taken) or in the event of pregnancy or a desire to become pregnant.

ART can sometimes be simplified. However, it is essential to maintain virological control. Consequently,it is not always possible to change therapy : therapeutic history, potential presence of mutations and resistance, and possible presence of co-infection with the hepatitis B virus (HBV) must all be taken into coonsideration.

Specific recommendations have been developed for the management of children and adolescents with HIV.

Upcoming publications

Other chapters of recommendations, produced under the aegis CNS and ANRS MIE, are also available:

Screening and management of cancer in people living with HIV
Diagnosis, virological monitoring of HIV infection and analysis of antiretroviral resistance
Care and follow-up of adults living with HIV
Organisation of and access to care, quality of life to ensure therapeutic success
Screening and management of co-morbidities in adults living with HIV
Prevention and screening for HIV infection
Epidemiology and social determinants of HIV infection in France

In addition, the French recommendations on other sexually transmitted infections are currently being updated. This is carried out at the request of the Ministry of Health by ANRS MIE and CNS, and approved by HAS.

How to access the recommendations and arguments:

To access the documents (arguments, recommendations, summary sheets, patient information sheets) available for each chapter, consult our ‘Expertise and Publications’ section or the HAS and CNS websites.

ANRS MIE CNS HAS