Treatment as Prevention
The new guidelines reflect the growing understanding that people on effective antiretroviral treatment who have an undetectable viral load (under 200) do not transmit the virus to their sex partners. The panel recommends that people starting treatment should use another form of prevention—for example, condoms or PrEP for a partner—for at least the first six months and until they receive an undetectable viral load test result.
First Two-Drug Initial Regimen
Dovato - For the first time, the guidelines include a two-drug combination to the list of recommended regimens for starting treatment; such recommendations were previously limited to three-drug regimens. The other approved two-drug single-tablet regimen, Juluca (dolutegravir/rilpivirine), is only for people who switch treatment with an undetectable viral load, not for initial therapy.
Rapid Treatment Initiation
The guidelines recommend that antiretroviral therapy should be started immediately or as soon as possible after HIV diagnosis. For those with acute or recent infection, the panel added Biktarvy (bictegravir/tenofovir alafenamide/emtricitabine) as a recommended option for those who will start treatment before resistance test results are available.
Cost Considerations
The guidelines have an updated section on cost considerations related to antiretroviral treatment, including an overview of the individual and societal costs of HIV care in the United States. A new subsection on cost sharing looks at how cost-containment practices may affect out-of-pocket payments for people with Medicaid, Medicare and AIDS Drug Assistance Program (ADAP) coverage. The section also features a revised discussion about the increased cost of brand-name antiretrovirals and the expected impact of generic regimens as these drugs go off patent.
Tuberculosis
The tuberculosis section has been updated with new data on short-course regimens for the treatment of latent tuberculosis and new data on drug interactions between antiretrovirals and the TB drugs rifampin and rifapentine.