Whilst we should try to adhere to the guidelines re PJP prophylaxis for sustained CD4 counts over 200 prior to cessation, there is enough reason to not panick if a patient is having difficulty being adherent , and

1. Their CD4 count is above 100, or

2. Their CD4 count is above 75 and the viral load is <400

and

3. They do not have underlying lung disease or another cause of immunodeficiency.

This particularly useful to have in mind for those patients with difficulty with adherence and a Bactrim allergy! It might be easier to prioritise another medication as opposed to upset rapport by trying to administer pentamidine or atovaquone which are less efficacious.

Matthew Shields has already done an excellent summary of the three most interesting presentations in "Antiviral therapy 1".

I will try to add a few points without doubling too much over the content.

Follow up of all small cohorts were to 24 weeks only.

The first presentation was on dolutegravir 50mg bd monotherapy in virologically suppressed treatment experienced individuals with healthy CD4 counts (many on atypical regimens including PI monotherapy) in a 33 patient "spur of the moment" pilot study. The authors explained 1 failure through extenuating psychosocial circumstances.

The second presentation from France was on dolutegravir 50mg once daily monotherapy in an older (mean 47, duration ART 17 years) virologically suppressed treatment experienced individuals (1/3 mono, 1/3 dual, 1/3 triple therapy). Three treatment failures were linked to resistance mutations in integrase but those identified were not classically for dolutegravir.

The third study was DTG+3TC in 20 treatment naive individuals and marked as sponsored by ViiV, who will fund a clinical trial soon in the area. Patients had viral loads less than 100,000 copies/ml and CD4 above 200. All patients had viral loads <400 copies by Week 3 and <50 by Week 8.

My conclusions were:

1. Follow up to 24 weeks was a significant limitation to these pilot studies. Further work is needed.

2. Dolutegravir resistance is certainly possible.

3. First line two drug dolutegravir containing therapy may certainly be a possibility, either with lamivudine or otherwise, but data is currently insufficient to support this.

4. Dolutegravir monotherapy could be considered in treatment experienced patients who have burnt out other options but there isn't enough to recommend switching for simplicity of regimen.

5. Early virological suppression does not necessarily translate to treatment efficacy.

I attended a few sessions of this course which runs on the first day. I hadn't read about the details beforehand, but it is very much in the style of an intensive workshop or refresher targeted towards specialist trainees or general or non-HIV physicians. I would certainly recommend attendance for these groups. Reference was also frequently made to the EACS Guidelines.

Both the toxicity session and the sexually transmitted infections session for instance comprised of a 15 minute clinical vignette of a moderate or higher complexity, followed by a 20-30 minute review on the topic. Particularly the toxicity session was ambitious and discussed about 20 items with traditional drug toxicity and all the metabolic complications.

The EACS Guidelines were updated and released in time for the conference.

If you have not viewed these guidelines previously, it might be worthwhile having a look via the link below.

They are quite distinct from, for example, the ASHM ARV guidelines. The EACS Guidelines almost present themselves as an exhaustive guide on how to approach all stages of HIV management, and even present flow diagrams on how to approach weight loss or discuss psychosocial issues in reasonable detail.

While they provide a good starting point, it is really important to remember that management often needs to be personalised or targeted to any given patient.

Download the Guidelines from EACS Society