GUIDELINES Version 10.010.1 NovemberOctober 2020 2019 English Table of Contents Introduction to EACS Guidelines 2020 2 Bone Disease: Screening and Diagnosis 61 Summary of Changes from v10.0 to v10.1 3 Vitamin D Deficiency: Diagnosis and Management 62 Panel Members 4 Approach to Fracture Reduction in PLWH 63 Governing Board Members 4 Kidney Disease: Definition, Diagnosis and Management 64 Abbreviations 5 ARV-associated Nephrotoxicity 65 Indications and Tests for Proximal Renal Tubulopathy (PRT) (66) Green text = online only at http://www.eacsociety.org and in the EACS Guidelines App. Page numbers in brackets refer to corresponding pages in Dose Adjustment of ARVs for Impaired Renal Function 67 the online version of the Guidelines. Work-up and Management of PLWH with 69 Increased ALT/AST Part I Liver Cirrhosis: Classification and Surveillance 70 Liver Cirrhosis: Management 71 Assessment of PLWH at Initial & Subsequent Visits 6 Non-Alcoholic Fatty Liver Disease (NAFLD) 72 Part II Diagnosis and Management of Hepatorenal Syndrome (HRS) (73) Dose Adjustment of ARVs for Impaired Hepatic Function 74 ART of PLWH 9 Lipoatrophy and Obesity: Prevention and Management (75) Assessing PLWH's Readiness to Start and Maintain ART 9 Hyperlactataemia and Lactic Acidosis: Diagnosis, Prevention (76) Recommendations for Initiation of ART in PLWH with Chronic Infection 11 and Management without prior ART Exposure Travel 77 Initial Combination Regimen for ART-naïve Adult PLWH 12 Drug-drug Interactions between Antimalarial Drugs and ARVs (78) Primary HIV Infection (PHI) 14 Vaccination 79 Switch Strategies for Virologically Suppressed Persons 15 Sexual and Reproductive Health of Women and Men Living with HIV 80 Virological Failure 16 Sexual Dysfunction (82) Treatment of Pregnant Women Living with HIV 17 Treatment of Sexual Dysfunction in Men Living with HIV (83) ART in TB/HIV Co-infection 20 Depression: Screening and Diagnosis 84 Post-exposure Prophylaxis (PEP) 22 Depression: Management 85 Pre-exposure Prophylaxis (PrEP) 23 Classification, Doses, Safety and Adverse Effects of Antidepressants 86 Adverse Effects of ARVs & Drug Classes 24 Drug-drug Interactions between Antidepressants and ARVs (87) Algorithm for Diagnosis & Management of Cognitive Impairment in 88 Part III PLWH without Obvious Confounding Conditions Drug-drug Interactions and Other Prescribing Issues in PLWH 26 Chronic Lung Disease in PLWH 89 Drug-drug Interactions between ARVs and Non-ARVs 27 Drug-drug Interactions between Bronchodilators (for COPD) and ARVs (90) Drug-drug Interactions between Antidepressants and ARVs (29) Drug-drug Interactions between Pulmonary Antihypertensives and (91) Drug-drug Interactions between Antihypertensives and ARVs (30) ARVs Drug-drug Interactions between Analgesics and ARVs (31) Frailty in the Context of Ageing 92 Drug-drug Interactions between Anticoagulants/Antiplatelet Agents and (32) Solid Organ Transplantation (SOT) in PLWH (93) ARVs Drug-drug Interactions between Immunosuppressants (for SOT) and (94) Drug-drug Interactions between Bronchodilators (for COPD) and ARVs (33) ARVs Drug-drug Interactions between Contraceptives and ARVs (34) Part V Drug-drug Interactions between Corticosteroids and ARVs (35) Drug-drug Interactions between Antimalarial Drugs and ARVs (36) Clinical Management and Treatment of Viral Hepatitis 95 Co-infections in PLWH Drug-drug Interactions between Pulmonary Antihypertensives and (37) ARVs General Recommendations for Persons with Viral Hepatitis/HIV 95 Co-infection Drug-drug Interactions between Immunosuppressants (for SOT) and (38) ARVs Treatment and Monitoring of Persons with HBV/HIV Co-infection 96 Drug-drug interactions between DAAs and ARVs (39) Treatment and Monitoring of Persons with HCV/HIV Co-infection 97 Administration of ARVs in PLWH with Swallowing Difficulties 40 HCV Treatment Options in HCV/HIV Co-infected Persons 98 Dose Adjustment of ARVs for Impaired Hepatic Function 42 Drug-drug Interactions between DAAs and ARVs (100) Dose Adjustment of ARVs for Impaired Renal Function 43 Algorithm for Management of Recently Acquired HCV Infection in 101 PLWH Selected Non-ARV Drugs Requiring Dosage Adjustment in Renal (45) Insufficiency Cut-off Values of Non-invasive Tests for the Detection of Advanced (102) Fibrosis and Cirrhosis Prescribing in Elderly PLWH 47 Hepatitis D and E in PLWH 103 Selected Top 10 Drug Classes to Avoid in Elderly PLWH (48) Dosage Recommendations for Hormone Therapy when Used at High (49) Part VI Doses for Gender Transitioning Opportunistic Infections 104 Part IV When to start ART in PLWH with Opportunistic Infections (OIs) 104 Prevention and Management of Co-morbidities in PLWH 50 Immune Reconstitution Syndrome (IRIS) 104 Drug Dependency and Drug Addiction (51) Primary Prophylaxis of OIs According to stage of Immunodefficiency 105 Cancer: Screening Methods 52 Primary Prophylaxis, Treatment and Secondary Prophylaxis/Mainte- 106 nance Treatment of Individual OIs Lifestyle Interventions 53 Diagnosis and Treatment of TB in PLWH 114 Prevention of Cardiovascular Disease (CVD) 54 TB Drugs Doses 117 Hypertension: Diagnosis, Grading and Management 55 Hypertension: Drug Sequencing Management 56 References Drug-drug Interactions between Antihypertensives and ARVs (57) Type 2 Diabetes: Diagnosis 58 Video Links (118) Type 2 Diabetes: Management 59 References to all sections (119) Dyslipidaemia 60 EACS European EACS Guidelines 10.1 1 AIDS Clinical Society Introduction to the EACS Guidelines 2020 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 The EACS Guidelines cover a relatively large and diverse area geograph- a separate section, see References. Please reference the EACS Guidelines ically, with different national levels of access to care. As a natural conse- as follows: EACS Guidelines version 10.1, October 2020. 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 2020 version of the Guidelines includes minor updates of all sections. The diagnosis and management of HIV infection and related co-infections, The most essential changes are listed in the Summary of changes from opportunistic diseases and comorbidities continue to require a multidiscipli- v10.0 to v10.1 nary effort for which we hope the 2020 version of the EACS Guidelines will provide you with an easily accessible and updated overview. 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! Georg Behrens and Lene Ryom October 2020 EACS European EACS Guidelines 10.1 2 AIDS Clinical Society Summary of Changes from v10.0 to v10.1 The COVID-19 situation is rapidly changing, and evidence is constantly Viral Hepatitis Co-infections section accumulating. Therefore, we refer to the regularly updated BHIVA, DAIG, EACS, GESIDA & Polish Scientific AIDS Society Statement on risk of • The main tables on HCV treatment options and DDIs have been updated, COVID-19 for PLWH https://www.eacsociety.org/home/covid-19-and-hiv.html pages 98-100 • Resistance testing guidance before