Prep, treatment initiation, pregnancy: what the new HIV recommendations change

In France, after having fallen significantly, the number of HIV infections has stabilized for three years. Various factors are involved and to try to do better, all the recommendations on HIV care were updated in 2024 by the National Council for AIDS and Viral Hepatitis (CNS), the National Agency for research on HIV/AIDS, viral hepatitis, tuberculosis, sexually transmitted infections and emerging infectious diseases (ANRS-MIE) and the High Authority for Health (HAS).

There are 15 of them, the recommendation sheets and associated scientific arguments cover preventive treatments, screening, treatment of people living with HIV (PLHIV) but also other long-term monitoring elements such as pregnancy, cancers, comorbidities or even infectious complications.

Prevention: neglect no one

The most important axis in the fight against HIV is the prevention of infection. One of the major new developments is the recommendation to expand access to pre-exposure prophylaxis (Prep) and post-exposure treatment (TPE) to people in very precarious situations, less educated or born abroad because they are far from the prevention circuits. “Everyone who needs it at some point in their sex life must be able to use Prep”explains Dr Cédric Arvieux, infectious disease specialist at Rennes University Hospital. And remember that any doctor can prescribe this prophylaxis. The members of the working groups recommend experimenting with new methods of delivering TPE in community pharmacies or through associations already authorized for screening.

“The link between social determinants and access to prevention, screening and care is strong”indicates Karen Champenois, epidemiologist at Inserm, who co-led the working group on the subject. The production of quality indicators from the national to the fine territorial scale is essential: “If we ignore the population we are targeting and the main obstacles to prevention, we will not be successful regardless of the time spent”she emphasizes.

Caregivers are fully involved in disseminating prevention messages to their patients. “The message I = I (undetectable = untransmittable in the context of sexual relations, Editor’s note) is a major factor in the reduction in the number of new diagnoses and must be known even outside the circle of PLHIV. All healthcare staff must know and be convinced of this message”insists Karen Champenois, recalling that the viral load is undetectable from six months on antiretrovirals.

Screening with a population approach

Prevention goes hand in hand with screening. In France in 2023, more than 10,000 people were unaware of their HIV status. Late diagnosis constitutes a loss of individual and collective opportunity. In order to shorten the time for entry into care, the diagnostic algorithm has been revised: from the first positive Elisa serological test, the second sample is taken and analyzed, without waiting for the Western Blot results. This allows the diagnosis to be validated within seven days and improves the efficiency of the first consultation.

The inventory of screening offers has demonstrated their complementarity within the healthcare system but also outside it, which justifies increasing the opportunities to offer a test and adapting to target populations. “We must encourage the repetition of screening of exposed populations. To do this, we must promote independent screening: self-testing and home sampling”explains Karen Champenois.

Dr Catherine Dollfus, pediatrician at Trousseau Hospital (AP-HP) and co-author of the report on pregnancy, recalls the importance of screening future fathers during the pregnancy project, an act included in national recommendations since fifteen years. “ We had worked to obtain an assessment fully covered by social security, but this has never really become widespread, very few general practitioners and midwives prescribe it”she laments. And to add: “as soon as the mother is screened negative, the healthcare body no longer considers the father, while women are contaminated by their partner during pregnancy or breastfeeding”.

Treat as quickly as possible

The time limit for initiating antiretroviral treatment (ARV) has been re-specified: initiation of ARV treatment must be done within two weeks (14 days) following diagnosis, to obtain virological control as quickly as possible. Therefore, it is not essential to wait for all the results of the initial assessment: as soon as the diagnosis is certain, treatment must begin. This period can nevertheless be adjusted in certain cases: for example for a pregnancy on the 3rd^e trimester, a primary infection or for an applicant with multiple partners, treatment must be initiated from the first consultation. Conversely, it is sometimes possible to delay treatment (HIV-2, low viral load or people who are not ready). In the event of opportunistic infection, a delay is necessary in two specific cases: neuromeningeal tuberculosis and neuromeningeal cryptococcus infection.

The guidelines for first-line molecules have been simplified: daily dual or triple therapy for HIV-1 (tritherapy for HIV-2), in a single oral tablet, is recommended in order to improve compliance. Several options are proposed: tri- or dual therapy with an integrase inhibitor or triple therapy with a non-nucleoside reverse transcriptase inhibitor. In the event of virological success, it will be possible to move from tri- to daily oral dual therapy or to bimonthly injectable dual therapy. Lenacapavir could allow injections every six months. Another option, supported by the ANRS-MIE Quatuor study: intermittent triple therapy, taken four days a week.

Even if fewer and fewer people are in virological failure, the situation can still arise. It is recommended to analyze the cause of failure (compliance, drug interactions, resistance) before changing ARVs, for current or new molecules. “Whatever the context, in 2024, antiretroviral treatment must result in maintained control of viral replication. It is at the heart of the national strategy aimed at eliminating transmission by 2030”insists Professor André Cabié, infectious disease specialist at Martinique University Hospital.

Lifelong support

Once treatment has been initiated, life plans must be supported. In a chapter on the pregnancy project, the working group wanted “open the door to breastfeeding”, rejoices Dr. Dollfus. Although breastfeeding is the main cause of HIV transmission worldwide, the risk decreases significantly when the viral load is undetectable. Under certain conditions (undetectable viral load at the latest before 1^is trimester then maintained, mother’s commitment to reinforced postnatal monitoring, good compliance), breastfeeding can be considered. It must then be exclusive if possible and last a maximum of six months.

PLHIV, thanks to the effectiveness of recent treatments, are seeing their life expectancy align with the general population. The institutions have thus issued recommendations on the specific monitoring of HIV in the context of aging: screening for cancers but also for various comorbidities (cardiovascular risk, dyslipidemia, endocrine and metabolic diseases, etc.). Recommendations regarding vaccination, currently being validated, are expected soon.