BHIVA guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015 (2016 interim update) Writing Group Laura Waters Chair N Ahmed, B Angus, M Boffito, M Bower, D Churchill, D Dunn, S Edwards, C Emerson, S Fidler, †M Fisher, R Horne, S Khoo, C Leen, N Mackie, N Marshall, F Monteiro, M Nelson, C Orkin, A Palfreeman, S Pett, A Phillips, F Post, A Pozniak, I Reeves, C Sabin, R Trevelion, J Walsh, E Wilkins, I Williams, A Winston †Professor Martin Fisher died in April 2015 – he made a significant contribution to these, many other guidelines and our speciality as a whole – he is greatly missed. August 2016 1 BHIVA guidelines for the treatment of HIV-1-positive adults with ART 2015 (2016 interim update) Table of contents Table of contents ................................................................................................................................... 2 1.0 Introduction ..................................................................................................................................... 6 1.1 Scope and purpose ..................................................................................................................................... 6 1.2 Methodology ............................................................................................................................................. 6 1.2.1 Guideline development process ......................................................................................................... 6 1.2.2 Involvement of PLWH ......................................................................................................................... 6 1.2.3 GRADE ................................................................................................................................................. 7 1.2.4 Good practice points .......................................................................................................................... 8 1.2.5 Dissemination and implementation ................................................................................................... 8 1.2.6 Guideline updates and date of next review ....................................................................................... 8 1.3 Treatment aims ......................................................................................................................................... 8 1.4 Resource use .............................................................................................................................................. 9 1.5 Implications for research ......................................................................................................................... 10 1.6 References ............................................................................................................................................... 10 2.0 Summary of recommendations ..................................................................................................... 12 3.0 Involvement of people living with HIV in decision-making ........................................................... 25 3.1 Recommendations ................................................................................................................................... 25 3.2 Auditable outcomes ................................................................................................................................. 25 3.3 Rationale .................................................................................................................................................. 25 3.4 References ............................................................................................................................................... 27 4.0 When to start ................................................................................................................................. 30 4.1 Chronic infection ...................................................................................................................................... 30 4.1.1 Recommendations ............................................................................................................................ 30 4.1.2 Auditable outcomes ......................................................................................................................... 30 4.1.3 Rationale ........................................................................................................................................... 30 4.1.4 References ........................................................................................................................................ 31 4.2 Individuals presenting with AIDS or a major infection ............................................................................ 32 4.2.1 Recommendation ............................................................................................................................. 32 4.2.2 Auditable outcome ........................................................................................................................... 32 4.2.3 Rationale ........................................................................................................................................... 32 4.2.4 References ........................................................................................................................................ 32 4.3 Treatment of primary HIV infection ......................................................................................................... 33 4.3.1 Recommendation ............................................................................................................................. 33 4.3.2 Auditable outcomes ......................................................................................................................... 33 4.3.3 Rationale ........................................................................................................................................... 33 4.3.4 References ........................................................................................................................................ 35 4.4 Impact of treatment on prevention of onward transmission .................................................................. 37 4.4.1 Recommendations ............................................................................................................................ 37 4.4.2 Auditable outcome ........................................................................................................................... 37 4.4.3 Rationale ........................................................................................................................................... 37 4.4.4 References ........................................................................................................................................ 38 5.0 What to start .................................................................................................................................. 40 5.1 Summary of recommendations ............................................................................................................... 40 5.1.1 Summary of auditable outcomes ..................................................................................................... 40 5.2 Introduction ............................................................................................................................................. 41 August 2016 2 BHIVA guidelines for the treatment of HIV-1-positive adults with ART 2015 (2016 interim update) 5.3 Which nucleoside reverse transcriptase inhibitor backbone ................................................................... 41 5.3.1 Recommendations ............................................................................................................................ 41 5.3.2 Rationale ........................................................................................................................................... 41 5.3.3 Not recommended ........................................................................................................................... 43 5.3.4 Lamivudine vs. emtricitabine ........................................................................................................... 43 5.3.5 References ........................................................................................................................................ 44 5.4 Which third agent .................................................................................................................................... 47 5.4.1 Recommendations ............................................................................................................................ 47 5.4.2 Rationale ........................................................................................................................................... 47 5.4.3 Individual agents............................................................................................................................... 47 References ................................................................................................................................................. 51 5.5 Novel antiretroviral therapy strategies ................................................................................................... 54 5.5.1 Recommendation ............................................................................................................................