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EACS Guidelines Version 10.0, November 2019

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GUIDELINES Version 10.0 November 2019 English Table of Contents Bone Disease: Screening and Diagnosis 61 Vitamin D Deficiency: Diagnosis and Management 62 Introduction to EACS Guidelines 2019 2 Approach to Fracture Reduction in PLWH 63 Summary of Changes from v9.1 to v10.0 3 Kidney Disease: Definition, Diagnosis and Management 64 Panel Members 4 ARV-associated Nephrotoxicity 65 Governing Board Members 4 Indications and Tests for Proximal Renal Tubulopathy (PRT) (66) Abbreviations 5 Dose Adjustment of ARVs for Impaired Renal Function 67 Work-up and Management of PLWH with 69 Green text = online only at http://www.eacsociety.org and in the Increased ALT/AST Page numbers in brackets refer to corre- EACS Guidelines App. Liver Cirrhosis: Classification and Surveillance 70 sponding pages in the online version of the Guidelines. Liver Cirrhosis: Management 71 Part I Non-Alcoholic Fatty Liver Disease (NAFLD) 72 Diagnosis and Management of Hepatorenal Syndrome (HRS) (73) Assessment of PLWH at Initial & Subsequent Visits 6 Dose Adjustment of ARVs for Impaired Hepatic Function 74 Part II Lipoatrophy and Obesity: Prevention and Management (75) Hyperlactataemia and Lactic Acidosis: Diagnosis, Prevention (76) ART of PLWH 9 and Management Assessing PLWH's Readiness to Start and Maintain ART 9 Travel 77 Recommendations for Initiation of ART in PLWH with Chronic Infection 11 Drug-drug Interactions between Antimalarial Drugs and ARVs (78) without prior ART Exposure Vaccination 79 Initial Combination Regimen for ART-naïve Adult PLWH 12 Sexual and Reproductive Health of Women and Men Living with HIV 80 Primary HIV Infection (PHI) 14 Sexual Dysfunction (82) Switch Strategies for Virologically Suppressed Persons 15 Treatment of Sexual Dysfunction in Men Living with HIV (83) Virological Failure 16 Depression: Screening and Diagnosis 84 Treatment of Pregnant Women Living with HIV 17 Depression: Management 85 ART in TB/HIV Co-infection 20 Classification, Doses, Safety and Adverse Effects of Antidepressants 86 Post-exposure Prophylaxis (PEP) 22 Drug-drug Interactions between Antidepressants and ARVs (87) Pre-exposure Prophylaxis (PrEP) 23 Algorithm for Diagnosis & Management of Cognitive Impairment in 88 Adverse Effects of ARVs & Drug Classes 24 PLWH without Obvious Confounding Conditions Part III Chronic Lung Disease in PLWH 89 Drug-drug Interactions between Bronchodilators (for COPD) and ARVs (90) Drug-drug Interactions and Other Prescribing Issues in PLWH 26 Drug-drug Interactions between Pulmonary Antihypertensives and (91) Drug-drug Interactions between ARVs and Non-ARVs 27 ARVs Drug-drug Interactions between Antidepressants and ARVs (29) Frailty in the Context of Ageing 92 Drug-drug Interactions between Antihypertensives and ARVs (30) Solid Organ Transplantation (SOT) in PLWH (93) Drug-drug Interactions between Analgesics and ARVs (31) Drug-drug Interactions between Immunosuppressants (for SOT) and (94) Drug-drug Interactions between Anticoagulants/Antiplatelet Agents and (32) ARVs ARVs Part V Drug-drug Interactions between Bronchodilators (for COPD) and ARVs (33) Drug-drug Interactions between Contraceptives and ARVs (34) Clinical Management and Treatment of Viral Hepatitis Co-infec- 95 Drug-drug Interactions between Corticosteroids and ARVs (35) tions in PLWH Drug-drug Interactions between Antimalarial Drugs and ARVs (36) General Recommendations for Persons with Viral Hepatitis/HIV 95 Co-infection Drug-drug Interactions between Pulmonary Antihypertensives and (37) ARVs Treatment and Monitoring of Persons with HBV/HIV Co-infection 96 Drug-drug Interactions between Immunosuppressants (for SOT) and (38) Treatment and Monitoring of Persons with HCV/HIV Co-infection 97 ARVs HCV Treatment Options in HCV/HIV Co-infected Persons 98 Drug-drug interactions between DAAs and ARVs (39) Drug-drug Interactions between DAAs and ARVs (100) Administration of ARVs in PLWH with Swallowing Difficulties 40 Algorithm for Management of Recently Acquired HCV Infection in 101 Dose Adjustment of ARVs for Impaired Hepatic Function 42 PLWH Dose Adjustment of ARVs for Impaired Renal Function 43 Cut-off Values of Non-invasive Tests for the Detection of Significant (102) Fibrosis and Cirrhosis Selected Non-ARV Drugs Requiring Dosage Adjustment in Renal (45) Insufficiency Hepatitis D and E in PLWH 103 Prescribing in Elderly PLWH 47 Part VI Selected Top 10 Drug Classes to Avoid in Elderly PLWH (48) Dosage Recommendations for Hormone Therapy when Used at High (49) Opportunistic Infections 104 Doses for Gender Transitioning When to start ART in PLWH with Opportunistic Infections (OIs) 104 Part IV Immune Reconstitution Syndrome (IRIS) 104 Primary Prophylaxis of OIs According to stage of Immunodefficiency 105 Prevention and Management of Co-morbidities in PLWH 50 Primary Prophylaxis, Treatment and Secondary Prophylaxis/Mainte- 106 Drug Dependency and Drug Addiction (51) nance Treatment of Individual OIs Cancer: Screening Methods 52 Diagnosis and Treatment of TB in PLWH 114 Lifestyle Interventions 53 TB Drugs Doses 117 Prevention of Cardiovascular Disease (CVD) 54 References Hypertension: Diagnosis, Grading and Management 55 Hypertension: Drug Sequencing Management 56 Video Links (118) Drug-drug Interactions between Antihypertensives and ARVs (57) References to all sections (119) Type 2 Diabetes: Diagnosis 58 Type 2 Diabetes: Management 59 Dyslipidaemia 60 EACS European EACS Guidelines 10.0 1 AIDS Clinical Society Introduction to the EACS Guidelines 2019 Welcome to the EACS Guidelines! Each respective section of the Guidelines is managed by a panel of expe- rienced European HIV experts, with additional experts in other fields of ex- These Guidelines were developed by the European AIDS Clinical Society pertise included where necessary. All recommendations are evidence-based (EACS), a not-for-profit organisation, whose mission is to promote excel- whenever possible and based on expert opinions in the rare instances where lence in standards of care, research and education in HIV infection and re- adequate evidence is unavailable. The Guidelines do not provide formal lated co-infections, and to actively engage in the formulation of public health grades of evidence, panels make decisions by consensus or by vote when policy, with the aim of reducing the HIV disease burden across Europe. necessary and we do not publish results of the votes or discrepancies if any occur. The EACS Guidelines were first published in 2005, and are currently avail- able in print, online as a pdf and web-based version, and as a free App for The EACS Guidelines panels are overseen by a Guidelines Chair who both iOS and Android devices. The Guidelines are translated into several dif- serves a three-year term and is elected from the Governing Board. Each ferent languages and are formally revised at least annually for the electronic panel is led by a Panel Chair, supported by a Vice-Chair and a Young version and biennially for the printed version. The electronic version can, Scientist. The Co-Chair will take over the role of Chair after the Chair’s term however, be updated at any time if the panels consider it necessary. expires. Panel membership is reviewed annually and rotation is overseen by the Panel Leads and Guidelines Chair according to a standard The aim of the EACS Guidelines is to provide easily accessible and compre- operating procedure. Operational matters of the EACS Guidelines are led by hensive recommendations to clinicians involved in the care of people living a Coordinator in the Medical Secretariat, supported by the EACS Secretariat. with HIV (PLWH). A list of the main references used to produce the Guidelines is provided as a The EACS Guidelines cover a relatively large and diverse area geograph- separate section, see References. Please reference the EACS Guidelines as ically, with different national levels of access to care. As a natural conse- follows: EACS Guidelines version 10.0, November 2019. Video links to the quence, the Guidelines aim to cover a relatively wide range of recommenda- EACS online course on Clinical Management of HIV are provided throughout tions as opposed to the often more uniform national guidelines. the Guidelines, see Video links. The 2019 version of the Guidelines introduces a new drug-drug interaction The diagnosis and management of HIV infection and related co-infections, panel and now consists of six main sections, including a general over- opportunistic diseases and comorbidities continue to require a multidiscipli- view table of all major issues in PLWH, recommendations on antiretroviral nary effort for which we hope the 2019 version of the EACS Guidelines will treatment, drug-drug interactions, diagnosis, monitoring and treatment of provide you with an easily accessible and updated overview. co-morbidities, co-infections and opportunistic diseases. All comments to the Guidelines are welcome and can be directed to [email protected] We wish to warmly thank all panellists, external experts, linguists, transla- tors, the EACS Secretariat, the Sanford team and everyone else who helped to build up and to publish the EACS Guidelines for their dedicated work. Enjoy! Manuel Battegay and Lene Ryom November 2019 EACS European EACS Guidelines 10.0 2 AIDS Clinical Society Summary of Changes from v9.1 to v10.0 • In the section on depression, there is a statement on the impact of ART section depression on overall well-being, page 84 • What to start with, pages 12-13 • In the cognitive guidelines, recommendations for modification ofART • New recommendation favouring
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