The National Council for AIDS and Viral Hepatitis (CNS), the ANRS – Emerging Infectious Diseases (ANRS-MIE) and the High Authority for Health (HAS) have updated the 15 recommendation sheets on prevention and treatment. care of people living with HIV (PLHIV). They cover prophylaxis, screening, treatment, but also long-term monitoring: pregnancy, cancers, comorbidities and infectious complications.
One of the major new developments is the recommendation to extend access to pre-exposure prophylaxis (Prep) to anyone at increased risk of exposure, as well as to anyone who requests it, even without an identified risk. The experts point out that any doctor is authorized to prescribe it and wish to extend this authorization to midwives. They call for simplifying the care pathway with less burdensome surveillance. Access to post-exposure treatment (PET) must also be expanded, and its dispensation simplified by new delivery methods (community pharmacy or authorized associations).
Breastfeeding authorized under certain conditions
The time limit for starting antiretroviral treatment (ARV) has been re-specified: treatment must begin within 14 days of diagnosis (the algorithm of which has also been revised to validate the result within seven days). Therefore, it is not essential to wait for all the results of the initial assessment. The guidelines for first-line molecules have been simplified: daily bi- or triple therapy for HIV-1 (tritherapy for HIV-2), in a single oral tablet in order to improve compliance. In the event of virological success, other regimens are possible: switching from triple therapy to daily oral dual therapy or to bimonthly injectable dual therapy or even intermittent triple therapy (four days per week).
The pregnancy journey of women living with HIV must be supported (preconception, perinatal treatment, obstetric follow-up). Unprecedented announcement: breastfeeding is possible, under strict conditions to protect the child (viral load undetectable since 1is trimester, reinforced monitoring, compliance, postnatal prophylaxis of the baby).
For children living with HIV, treatment must be initiated as early as possible – particularly in infants and in cases of severe immune deficiency – and progress with age (galenic, adverse effects). The information given to the child must be progressive according to his age. Experts emphasize the difficulties linked to adolescence, a pivotal period at risk of non-compliance and during which appropriation of the diagnosis and its implications is difficult. They remind us of the importance of supporting the transition to adulthood.
Associated pathologies: specific treatment
The infectious complications accompanying HIV (pneumocystosis, tuberculosis, candida, etc.) remain a significant problem. Primary or secondary prophylaxis is recommended for certain infections, which can be interrupted once immune reconstitution under ARV is sufficient.
The effectiveness of treatments is increasing and the life expectancy of PLHIV is aligning with the general population. The institutions have thus issued recommendations on the specific monitoring of HIV in the context of aging: comorbidities (cardiovascular, endocrine, metabolic diseases, etc.) and cancers.
In cancer, experts invite consider HIV “only” as a comorbidity. Screening strategies are similar to the general population, except for anal cancers due to HPV (high prevalence). As for therapeutic care, it is the ARV treatment that adapts to the oncological treatment (and not the other way around), except in cases of HBV or HCV co-infection (risk of reactivation of hepatitis) and bronchopulmonary cancer (drug interactions).
Long-acting ARVs are a game changer
Long-acting (LA) formulations are gaining popularity to facilitate compliance. Curative treatments are already available and several studies confirm their preventive effectiveness and their superiority to oral forms, as is the case for bimonthly injectable cabotegravir. Revolution of 2024: Gilead’s lenacapavir, which won the prize Science of innovation in 2024, has proven to be extremely effective as a preventative measure in cis women, with two injections per year. After numerous international calls to make it accessible throughout the world, the pharmaceutical giant concluded a voluntary licensing agreement at the beginning of October with six generic manufacturers for distribution in 120 countries.
