Executive summary of the GESIDA/National AIDS Plan Consensus Document on Antiretroviral Therapy in Adults Infected by the Human Immunodeficiency Virus (Updated January 2017) | Enfermedades Infecciosas y Microbiología Clínica

array:22 ["pii" => "S0213005X17301313" "issn" => "0213005X" "doi" => "10.1016/j.eimc.2017.04.001" "estado" => "S300" "fechaPublicacion" => "2018-08-01" "aid" => "1690" "copyrightAnyo" => "2017" "documento" => "article" "crossmark" => 1 "subdocumento" => "pgl" "cita" => "Enferm Infecc Microbiol Clin. 2018;36:435-45" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 988 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 565 "PDF" => 420 ] ] "itemSiguiente" => array:19 [ "pii" => "S0213005X17303002" "issn" => "0213005X" "doi" => "10.1016/j.eimc.2017.10.006" "estado" => "S300" "fechaPublicacion" => "2018-08-01" "aid" => "1758" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Enferm Infecc Microbiol Clin. 2018;36:446-55" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3072 "formatos" => array:3 [ "EPUB" => 1 "HTML" => 1972 "PDF" => 1099 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Formación médica continuada: Infecciones por micobacterias" "titulo" => "Tuberculosis e inmigración" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "446" "paginaFinal" => "455" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Tuberculosis and immigration" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1909 "Ancho" => 2799 "Tamanyo" => 412561 ] ] "descripcion" => array:1 [ "es" => "Tasas de notificación de tuberculosis en inmigrantes y autóctonos y proporción de TB diagnosticadas en inmigrante del total.Fuente: Framework towards tuberculosis elimination in low-incidence countries. Geneva: World Health Organization; 2014." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Adrián Sánchez-Montalvá, Fernando Salvador, Daniel Molina-Morant, Israel Molina" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Adrián" "apellidos" => "Sánchez-Montalvá" ] 1 => array:2 [ "nombre" => "Fernando" "apellidos" => "Salvador" ] 2 => array:2 [ "nombre" => "Daniel" "apellidos" => "Molina-Morant" ] 3 => array:2 [ "nombre" => "Israel" "apellidos" => "Molina" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529993X18301321" "doi" => "10.1016/j.eimce.2018.05.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X18301321?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17303002?idApp=UINPBA00004N" "url" => "/0213005X/0000003600000007/v1_201807240423/S0213005X17303002/v1_201807240423/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0213005X17302343" "issn" => "0213005X" "doi" => "10.1016/j.eimc.2017.09.002" "estado" => "S300" "fechaPublicacion" => "2018-08-01" "aid" => "1739" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Enferm Infecc Microbiol Clin. 2018;36:431-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1761 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 1507 "PDF" => 251 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "Original breve" "titulo" => "Prevalencia de especies del complejo Burkholderia cepacia en pacientes con fibrosis quística en Argentina durante el período 2011-2015" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "431" "paginaFinal" => "434" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Prevalence of Burkholderia cepacia complex species in cystic fibrosis patients in Argentina during the period 2011-2015" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Lucía Cipolla, Florencia Rocca, Claudia Martinez, Lorena Aguerre, Rubén Barrios, Mónica Prieto" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Lucía" "apellidos" => "Cipolla" ] 1 => array:2 [ "nombre" => "Florencia" "apellidos" => "Rocca" ] 2 => array:2 [ "nombre" => "Claudia" "apellidos" => "Martinez" ] 3 => array:2 [ "nombre" => "Lorena" "apellidos" => "Aguerre" ] 4 => array:2 [ "nombre" => "Rubén" "apellidos" => "Barrios" ] 5 => array:2 [ "nombre" => "Mónica" "apellidos" => "Prieto" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529993X1830131X" "doi" => "10.1016/j.eimce.2018.05.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X1830131X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17302343?idApp=UINPBA00004N" "url" => "/0213005X/0000003600000007/v1_201807240423/S0213005X17302343/v1_201807240423/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Consensus statement" "titulo" => "Executive summary of the GESIDA/National AIDS Plan Consensus Document on Antiretroviral Therapy in Adults Infected by the Human Immunodeficiency Virus (Updated January 2017)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "435" "paginaFinal" => "445" ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "" "autores" => array:1 [ 0 => array:2 [ "colaborador" => "AIDS Study Group (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology and the National AIDS Plan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resumen ejecutivo del Documento de consenso de GESIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (Actualización enero 2017)" ] ] "textoCompleto" => "IntroductionThe complexity and speed of changes of antiretroviral therapy (ART) requires frequent updating of specific guidelines. For the last 18 years, GESIDA and the National AIDS Plan have jointly edited a consensus document on ART in adults.<a class="elsevierStyleCrossRef" href="#bib0015">1</a> The objective of this consensus document, which updates previous recommendations,<a class="elsevierStyleCrossRef" href="#bib0020">2</a> is to provide health professionals who treat HIV-infected adults with up-to-date knowledge on ART and a series of recommendations based on scientific evidence that can act as guidelines in therapeutic decision making.Clinical and laboratory evaluation as a guide for ARTClinical evaluationRecommendations<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•A clinical history should be taken for all HIV-infected patients. The history should include an evaluation of the patient's drug therapy, comorbid conditions, and risk of STI. The patient should also undergo a thorough physical examination, which should be repeated once a year (A-II).</li><li class="elsevierStyleListItem" id="lsti0010">•In all newly diagnosed cases, all previous sexual contacts should be evaluated after agreement with the index case and with confidentiality guaranteed (B-III).</li></ul>Laboratory testsRecommendations<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">•Serology testing for HIV should be performed in all cases where HIV infection has not been confirmed and the plasma viral load (PVL) is undetectable (A-I).</li><li class="elsevierStyleListItem" id="lsti0020">•The initial laboratory workup should include a complete blood count, general biochemistry, and serology testing (Toxoplasma, cytomegalovirus, syphilis, HAV, HBV, and HCV). Specific tests, including viral load, CD4+ T-lymphocyte count, primary resistance to HIV and HLA-B*5701, should also be performed (A-II).</li></ul>CD4+ lymphocytesRecommendations<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025">•The absolute number and percentage of CD4+ T lymphocytes should be determined before initiating ART. Once therapy has started, these determinations should be made periodically every 3–6 months to monitor the immune response (A-I).</li><li class="elsevierStyleListItem" id="lsti0030">•Determinations can be at longer intervals, at the physician's discretion, in stable patients with suppressed plasma viral load (PVL) and CD4+ T-lymphocyte counts >300cells/μL (C-II).</li></ul>Plasma viral loadRecommendations<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035">•PVL should be determined before initiation of ART and regularly during treatment (A-II).</li><li class="elsevierStyleListItem" id="lsti0040">•PVL is the main parameter for evaluating the virological efficacy of ART and for defining virological failure (A-I).</li><li class="elsevierStyleListItem" id="lsti0045">•The objectives of virological suppression (VL <50copies/mL) should be met both in ART-naïve patients and in those who have experienced previous therapeutic failure (A-II).</li><li class="elsevierStyleListItem" id="lsti0050">•PVL should be determined using a technique with a quantification limit of at least 50copies/mL. The same technique should always be used (A-II).</li><li class="elsevierStyleListItem" id="lsti0055">•If decisions on therapy are to be taken based on PVL, they should be confirmed with a second determination (A-II).</li></ul>Plasma concentration of antiretroviral drugsRecommendations<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0060">•Determination of the plasma concentration of antiretroviral drugs is not recommended for habitual monitoring of HIV-infected patients (A-II).</li><li class="elsevierStyleListItem" id="lsti0065">•Determination of the plasma concentration of antiretroviral drugs may be indicated in specific clinical situations (e.g., risk of pharmacological interactions, organ transplantation, extreme underweight or overweight, pregnancy, and renal or hepatic insufficiency) and to confirm suspected poor adherence to therapy (B-III).</li></ul>Resistance of HIV-1 to antiretroviral drugsRecommendations<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070">•Genotyping of reverse transcriptase and protease to detect HIV resistance mutations should be performed in all patients at diagnosis of infection and before initiating ART if this is deferred (A-II).</li><li class="elsevierStyleListItem" id="lsti0075">•The result of the genotyping study should be known before starting ART with non-nucleoside reverse transcriptase inhibitors (NNRTI) (A-II).</li><li class="elsevierStyleListItem" id="lsti0080">•Assessment of baseline integrase resistance mutations is only recommended when there is a high suspicion of transmission of resistance to integrase strand transfer inhibitors (INSTI) (C-III).</li><li class="elsevierStyleListItem" id="lsti0085">•Resistance should be studied by genotyping in all patients in whom virological failure has been confirmed. The study should include integrase resistance mutations if the patient's regimen includes an INSTI (A-I).</li></ul>Determination of the HLA-B*5701 alleleRecommendations<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0090">•HLA-B*5701 should be determined in all patients before initiating an ART regimen containing ABC (A-I).</li><li class="elsevierStyleListItem" id="lsti0095">•ABC should not be prescribed if the result of the HLA-B*5701 determination is positive (A-I).</li></ul>Determination of tropismRecommendations<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100">•HIV-1 tropism should be determined before prescribing a CCR5 receptor antagonist (A-I).</li><li class="elsevierStyleListItem" id="lsti0105">•HIV-1 tropism should be determined if a regimen containing a CCR5 receptor antagonist fails (A-I).</li></ul>Initial antiretroviral therapyWhen should ART be initiated?Recommendations<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0110">•ART should be initiated in all HIV-infected patients.</li><li class="elsevierStyleListItem" id="lsti0115">•Initiation of ART should always be evaluated on an individual basis. Both CD4+ T-lymphocyte count and PVL should be determined before initiating ART. Furthermore, the patient should be briefed on the various options available, and the therapeutic regimen should be adapted to lifestyle, comorbid conditions, and possible drug interactions. The risk of poor adherence should also be assessed (A-III).</li></ul>Which combination of antiretroviral drugs should be used?Recommendation<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0120">•Initial ART can be a combination of 2 nucleoside reverse transcriptase inhibitors (NRTI) and 1 INSTI, 2 NRTI and 1 NNRTI, or 2 NRTI and 1 boosted protease inhibitor (PI) (A-I). Preferred antiretroviral drugs are set out in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</li></ul><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>1. NRTIRecommendations<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0125">•The NRTI combinations of choice for initial regimens are TAF/FTC or TDF/FTC and ABC/3TC (AI).</li><li class="elsevierStyleListItem" id="lsti0130">•Co-formulated preparations are recommended (A-II).</li><li class="elsevierStyleListItem" id="lsti0135">•The combination TDF/FTC should be avoided in patients with renal insufficiency (A-II).</li><li class="elsevierStyleListItem" id="lsti0140">•The combination ABC/3TC should be avoided in patients with a high PVL (>100,000copies/mL) when combined with an NNRTI or a boosted PI (A-II).</li></ul>2. NNRTIRecommendations<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0145">•The combinations rilpivirine (RPV)/TAF/FTC and RPV/TDF/FTC are considered preferential in patients with a PVL <100,000copies/mL, (A-I).</li><li class="elsevierStyleListItem" id="lsti0150">•RPV should not be administered to patients with a PVL >100,000copies/mL (A-II).</li><li class="elsevierStyleListItem" id="lsti0155">•Efavirenz (EFV) is contraindicated during the first trimester of pregnancy. Other options are recommended in women who do not use effective contraception. Similarly, EFV should be avoided in patients with neuropsychiatric disorders or a history of suicidal ideation and in patients who perform dangerous tasks if they present symptoms of somnolence, dizziness, and/or difficulty concentrating (A-III).</li></ul>3. PI boosted with ritonavir or cobicistat (PI/r or PI/c)Recommendations<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0160">•When it is deemed appropriate to initiate a PI-based regimen, the recommendation is for DRV/r or DRV/c+TDF/FTC or TAF/FTC (QD) (A-I). Alternatively, ATV/r or ATV/c+TDF/FTC or TAF/FTC (QD) could be prescribed (A-I).</li><li class="elsevierStyleListItem" id="lsti0165">•ATV and DRV can be boosted interchangeably with ritonavir 100mg or cobicistat 150mg (B-II).</li><li class="elsevierStyleListItem" id="lsti0170">•The combination DRV/r or DRV/c+ABC/3TC can also be used, although it has not been formally assessed in a clinical trial (B-III).</li><li class="elsevierStyleListItem" id="lsti0175">•DRV/r+RAL can be used as an alternative to conventional triple therapy when it is not possible to use TAF, TDF or ABC (B-I). This regimen should not be used as initial treatment in patients with advanced disease (CD4+ T-lymphocyte counts <200cells/μL and/or a PVL >100,000copies/mL) (A-I).</li></ul>4. INSTIRecommendations<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0180">•Dolutegravir (DTG) combined with TDF/FTC or TAF/FTC or coformulated with ABC/3TC, elvitegravir (EVG) coformulated with cobicistat/TAF/FTC (EVG/c/TAF/FTC), and raltegravir (RAL) combined with TDF/FTC or TAF/FTC are considered preferred regimens for initial treatment (A-I).</li><li class="elsevierStyleListItem" id="lsti0185">•The combination EVG/c/TAF/FTC is preferred over EVG/c/TDF/FTC owing to its better tolerability profile and the possibility of administering it with an estimated glomerular filtration rate (eGFR) >30mL/min (A-I).</li><li class="elsevierStyleListItem" id="lsti0190">•The combination EVG/c/TDF/FTC can be prescribed as an alternative, although not in patients with an estimated glomerular filtration rate <70mL/min) (A-I).</li></ul>Switching ART in patients with an undetectable PVLThere are several reasons for changing an efficacious ART regimen (e.g., tolerance, toxicity, comorbid conditions, drug interactions, and reducing the pill burden or number of daily doses).After switching ART in this context, maintenance of virological suppression and performance of relevant laboratory tests should be evaluated within 3–6 weeks.Remarks on the new regimenRecommendation<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0195">•In the case of patients with an undetectable PVL, the new regimen should give priority to the drugs recommended as preferential for naïve patients (A-III). In specific cases, alternative regimens, or regimens classed as “other antiretroviral regimens” (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) may be appropriate (A-II).</li></ul>Virological considerations when switching efficacious ARTRecommendation<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0200">•Switching from a regimen containing 2 NRTI+PI/r to one containing 2 NRTI+1 NNRTI, 1 INSTI or unboosted ATV is only possible if the antiviral activity of the 2 NRTI and third drug can be guaranteed (A-I).</li></ul>1. Switching drugs from the same family(a) NRTISwitching from ABC/3TC to TDF/FTCRecommendation<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0205">•The association between ABC and increased incidence of cardiovascular events is open to debate. This committee cannot make a recommendation on the strength of evidence for switching from ABC/3TC to TDF/FTC (C-I).</li></ul>Switching from TDF to ABCRecommendation<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0210">•The switch from TDF to ABC is a valid option in patients with osteopenia or osteoporosis associated with TDF (A-II).</li></ul>Switching from TDF/FTC to TAF/FTCRecommendation<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0215">•Switching from TDF/FTC to TAF/FTC is virologically safe. This switch is associated with improved bone mineral density and kidney function (A-I).</li></ul>(b) NNRTISwitching from EFV/TDF/FTC to RPV/TDF/FTCRecommendation<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0220">•In patients with adverse central nervous system (CNS) effects caused by EFV/TDF/FTC, the switch to RPV/TDF/FTC is one of the options that can improve the symptoms associated with EFV (A-II). There are no data in favor of recommending a proactive switch in patients who do not have CNS symptoms or data comparing this switch with a switch to other antiretroviral drugs that do not cause CNS effects.</li></ul>Switching from RPV/TDF/FTC to RPV/TAF/FTCRecommendation<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0225">•Switching from RPV/TDF/FTC or EFV/TDF/FTC to RPV/TAF/FTC is virologically safe. This switch is associated with improved bone mineral density and kidney function (A-I).</li></ul>Switching from EFV or NVP+2 NRTI to EFV/TDF/FTCRecommendation<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0230">•Switching to EFV/TDF/FTC is an option in patients taking ART with EFV and NVP who wish to reduce their pill burden (A-II).</li></ul>(c) Protease inhibitorsSwitching from ATV/r+ABC/3TC to unboosted ATV+ABC/3TCRecommendation<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0235">•In patients taking ATV/r+ABC/3TC, switching to ATV+ABC/3TC is a simplification option when attempting to avoid RTV, owing to hyperbilirubinemia, dyslipidemia, diarrhea, or the risk of interactions with RTV (A-I).</li></ul>Switching from ATV/r or DRV/r to ATV/c or DRV/cRecommendation<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0240">•In patients receiving treatment with ATV/r or DRV/r, switching to ATV/c (A-I) or DRV/c (A-II) is a simplification option that reduces the pill burden. The results of bioequivalence studies lead this Committee to recommend ATV/c or DRV/c interchangeably in contexts that affect ATV/r or DRV/r as a component of triple regimens (see elsewhere in this chapter). Data on dual regimens or monotherapy are not sufficient to recommend using the drugs interchangeably. Potential interactions with other drugs should always be taken into account, since these are not identical with ritonavir and with cobicistat.</li></ul>Switching from ATV/r+TDF/FTC to unboosted ATV+ABC/3TCRecommendation<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0245">•In patients taking ATV/r+TDF/FTC, switching to ATV+ABC/3TC is an option in those cases where both TDF and RTV have to be avoided (B-I).</li></ul>2. Switching to antiretroviral drugs from a different family(a) Switching from NRTI to INSTISwitching from TDF to RALRecommendation<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0250">•Switching from TDF to RAL in patients who are also taking a PI/r is also an option in patients with reduced bone mineral density (B-II).</li></ul>(b) Switching from NRTI to MVCRecommendation<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0255">•Switching to a boosted PI and MVC from regimens that contain 1 boosted PI and 2 NRTI is not virologically safe, although genotyping of proviral DNA shows that the virus is R5-tropic. This switch cannot be recommended (A-I).</li></ul>(c) Switching from NNRTI to INSTISwitching from EFV to RALRecommendations<ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0260">•Switching from EFV to RAL is an option in patients with CNS adverse events caused by EFV (A-II). There are no data to recommend a proactive change in patients with no CNS symptoms or data or data comparing this switch with a switch to other antiretroviral drugs that do not cause CNS effects.</li><li class="elsevierStyleListItem" id="lsti0265">•Switching from EFV to RAL is a valid option in patients with dyslipidemia caused by EFV (A-I).</li></ul>Switching from TDF/FTC+EFV or NVP to EVG/c/FTC/TDFRecommendation<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0270">•Switching from TDF/FTC+EFV or NVP to coformulated EVG/c/FTC/TDF is virologically safe. This change is an option for patients who wish to simplify their current regimen and can improve CNS symptoms caused by EFV (A-I). There are no data to recommend a proactive change in patients who do not have CNS symptoms. Similarly, there are no data comparing this switch with switches to other drugs that do not cause CNS symptoms.</li></ul>(d) Switching from boosted PI to an NNRTISwitching from a boosted PI to EFV/FTC/TDFRecommendation<ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0275">•Switching to EFV/FTC/TDF is an option in patients who are taking ART with boosted PI. This approach makes it possible to reduce the daily pill burden, although patients may experience EFV-induced CNS adverse effects (B-I).</li></ul>Switching from boosted PI to RPV/FTC/TDFRecommendation<ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0280">•Switching to an ART regimen comprising 2 NRTI and 1 boosted PI to the co-formulation RPV/FTC/TDF is a valid option in patients with gastrointestinal disorders or dyslipidemia. It also enables the daily pill burden to be reduced (A-I).</li></ul>(e) Switching from boosted PI to INSTISwitching from boosted PI to RALRecommendation<ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0285">•Switching to RAL+2 active NRTI is a valid option for patients with dyslipidemia taking ART with NRTI+1 boosted PI (B-I).</li></ul>Switching from boosted PI to EVG/c/FTC/TDFRecommendation<ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0290">•Switching from TDF/FTC+ATV/r or DRV/r or LPV/r to EVG/c/TDF/FTC is virologically better than the previous options. This switch is an option for patients who wish to simplify their current regimen and can improve RTV-associated digestive symptoms in some patients (A-I).</li></ul>(f) Switching to EVG/c/FTC/TAF from TDF-containing regimensRecommendation<ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0295">•Switching from EVG/c/FTC/TDF, EFV/FTC/TDF, or ATV/r+FTC/TDF to EVG/c/FTC/TAF is virologically safe in patients whose virus remains sensitive to all the components in the regimen. This change is also associated with improved bone mineral density and kidney function. The switch is even feasible in patients with mild or moderate kidney failure (A-I).</li></ul>(g) Switching to DTG/ABC/3TC from regimens containing 2 NRTI and PI, NNRTI, or INSTIRecommendation<ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0300">•Switching to DTG/ABC/3TC, from regimens containing 2 NRTI and PI, NNRTI, or INSTI is virologically safe. This switch is an option in patients who wish to simplify their current regimen.</li></ul>(h) Switch from a boosted PI to MVCRecommendation<ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0305">•Switching to 2 NRTI and MVC from regimens that contain 2 NRTI and PI is virologically safe if genotyping of proviral DNA shows that the virus is R5-tropic (A-I)</li></ul>3. Dual therapy with 3TC and ATV/r, DRV/r or LPV/rSwitching from 2 NRTI plus ATV/r, DRV/r, or LPV/r to 3TC plus ATV/r, DRV/r, or LPV/rRecommendation<ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0310">•Switching from 2 NRTI+ATV/r or DRV/r or LPV/r to dual therapy with 3TC+ATV/r or 3TC+DRV/r or 3TC+LPV/r is an option if the clinician wishes to avoid or prevent the adverse effects caused by NRTI. This option requires the patient to fulfill the following criteria: (1) No chronic hepatitis B; (2) PVL <50copies/mL for at least 6 months; and (3) No mutations in the protease gene or previous virological failure to PI/r or 3TC (A-I).</li></ul>4. Monotherapy with PI/rRecommendation<ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0315">•Monotherapy with DRV/r once daily or LPV/r twice daily is a valid option for treating or preventing adverse effects caused by NRTI if the patient fulfills the following criteria: (1) No chronic hepatitis B; (2) PVL <50copies/mL for at least 6 months; (3) No mutations in the protease gene and no previous virological failure with PI (B-I). Since there are no data on the efficacy of monotherapy with DRV/c, this regimen cannot be recommended at present. Given that monotherapy with DRV/r or LPV/r carries a greater risk of viral rebound than dual therapy with DRV/r or LPV/r with 3TC, this Committee recommends the use of monotherapy only in unusual cases where dual therapy cannot be used.</li></ul>Failure of ARTDefinition of virological failure (VF). Two confirmed determinations of PVL >50copies/mL 24 weeks after initiating ART.Recommendations<ul class="elsevierStyleList" id="lis0195"><li class="elsevierStyleListItem" id="lsti0320">•The objective of rescue ART is to achieve a PVL <50copies/mL (A-II).</li><li class="elsevierStyleListItem" id="lsti0325">•Switching ART because of VF should be performed early to avoid accumulation of mutations and to facilitate the response to the new treatment (A-III).</li><li class="elsevierStyleListItem" id="lsti0330">•The new ART regimen should contain 3 totally active antiretroviral drugs. If this is not possible, 2 fully active drugs should be combined with other drugs that maintain partial virological activity, especially in the case of advanced rescue in patients with limited therapeutic options (A-I). Regimens with only 2 active antiretroviral drugs based on a boosted PI may be a reasonable option in patients who have experienced a non-advanced failure when it is not possible to use NRTI or construct a simple regimen with 3 active drugs (A-I).</li><li class="elsevierStyleListItem" id="lsti0335">•Resistance and viral tropisms should be assessed in order to design the best alternative regimen. The test should be performed while the patient is receiving the failed treatment or as soon as possible after suspension of the failed treatment. If the results of previous genotyping tests are available, all the resistance mutations detected should be evaluated (A-I).</li><li class="elsevierStyleListItem" id="lsti0340">•The causes of VF—poor adherence, drug or food interactions, previous intolerance and previous toxicity—should be analyzed. The new regimen should be comfortable and well tolerated (A-III).</li><li class="elsevierStyleListItem" id="lsti0345">•In patients who have experienced VF, DRV/r is the PI/r that has proven most efficacious in all the rescue lines. When major resistance mutations are present, the recommended dose is 600/100mg BID (A-I).</li><li class="elsevierStyleListItem" id="lsti0350">•DTG is the INSTI of choice in patients who experience VF who are INSTI-naïve (A-I). In the case of previous failure to RAL or EVG, the recommended dose of DTG is 50mg BID, accompanied by optimized background therapy (A-II).</li><li class="elsevierStyleListItem" id="lsti0355">•The use of tipranavir/ritonavir (TPV/r), enfuvirtide, or thymidine analogs is restricted to patients with no other therapeutic options (A-III).</li><li class="elsevierStyleListItem" id="lsti0360">•In patients with low-grade VF (PVL detectable but ≤200copies/mL), genotyping can be performed with a 2–3–mL plasma sample (A-II). If genotyping does not reveal resistance mutations, an ART regimen with a high barrier to resistance should be maintained. In patients with a PVL >200copies/mL, genotyping should be performed. The choice of the new ART regimen should be based on both resistance mutations and previous ART. ART should not be intensified with a single drug (A-III).</li><li class="elsevierStyleListItem" id="lsti0365">•ART should not be suspended in patients with advanced VF and no therapeutic options (A-II). In this situation, the approach should involve antiretroviral drugs that reduce viral replicative capacity and do not lead to resistance mutations that might compromise future treatments (A-III).</li><li class="elsevierStyleListItem" id="lsti0370">•In patients with no therapeutic options, it is important to monitor the CD4+ count and PVL and to consult with clinicians and virologists specialized in resistance and rescue therapy who are involved in restricted access programs (B-III).</li></ul>Factors affecting the success of ART1. AdherenceRecommendations<ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0375">•Before initiating ART, the patient should be prepared and factors likely to limit adherence should be identified and corrected (A-III).</li><li class="elsevierStyleListItem" id="lsti0380">•Once ART has been initiated, a first check-up should be made after 2–4 weeks to verify adherence and correct adherence problems if necessary (A-III).</li><li class="elsevierStyleListItem" id="lsti0385">•Adherence should be monitored and reinforced at visits to the doctor (A-III).</li><li class="elsevierStyleListItem" id="lsti0390">•Adherence should be monitored by a multidisciplinary team including a doctor, nursing staff, specialists in psychological support, and a hospital pharmacist (A-III).</li><li class="elsevierStyleListItem" id="lsti0395">•In the case of patients whose adherence is irregular, it is recommended to use regimens based on boosted PI, preferably DRV because of its high genetic barrier to resistance, in order to prevent the development of resistance (A-II).</li><li class="elsevierStyleListItem" id="lsti0400">•Using fixed dose combinations of antiretroviral drugs simplifies ART and thus facilitates continued adherence. The use of whole regimens in a single tablet is the most efficient strategy for preventing selective poor adherence (A-II).</li></ul>2. Tolerability and adverse effects(a) Immediate adverse effectsRecommendations<ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0405">•Avoid the use of antiretroviral drugs whose immediate adverse effects are similar to clinical manifestations or laboratory abnormalities that are already present in a specific patient (A-II).</li><li class="elsevierStyleListItem" id="lsti0410">•HLA-B*5701 testing is mandatory before prescribing ABC, since it has a negative predictive value of almost 100% for the risk of hypersensitivity reaction to this drug (A-I).</li><li class="elsevierStyleListItem" id="lsti0415">•If the adverse effect is very intense or long-lasting or cannot be tolerated by the patient, the potential culprit antiretroviral drug(s) should be switched (A-I).</li></ul>(b) Late adverse effectsRecommendations<ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0420">•ART should be tailored by evaluating the risk or presence of chronic diseases in such a way that the regimen selected does not contain antiretroviral drugs that can favor the onset or progression of these diseases (A-II).</li><li class="elsevierStyleListItem" id="lsti0425">•Withdrawal of some of the antiretroviral drugs involved in late adverse effects can improve—albeit partially—the underlying clinical abnormality, although it is not known whether such a modification can alter the natural history of the specific chronic disease or survival. Antiretroviral drugs contribute collaterally to the risk or progression of specific chronic diseases, although other factors are generally considered to be more important. Priority should be given to interventions to address these factors (A-II).</li></ul>3. Drug interactionsRecommendations<ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0430">•All medications, natural products, alternative medicines and recreational drugs taken by the patient should be recorded in the clinical history in order to evaluate potential interactions (A-III).</li><li class="elsevierStyleListItem" id="lsti0435">•Contraindications should be taken into account and the corresponding dose adjustments made where necessary (A-I).</li><li class="elsevierStyleListItem" id="lsti0440">•Plasma levels should be monitored when prescribing two or more drugs with potential pharmacokinetic interactions in order to avoid toxicity or lack of efficacy (A-II).</li></ul>Special situations1. Acute HIV infectionRecommendations<ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0445">•ART should be recommended in all patients with acute HIV infection, regardless of the symptoms, their severity, or their duration (A-II) and should be started as soon as possible to obtain the maximum benefit.</li><li class="elsevierStyleListItem" id="lsti0450">•If ART is to be initiated, it should be done so with the same preferential regimens used to treat chronic HIV infection (A-I) (Table 1). A regimen comprising 2 NRTI (preferably TAF-TDF/FTC) and an INSTI could reduce PVL more rapidly during the first 4–8 weeks than PI or NNRTI and, thus, make it easier to reduce transmission of HIV (A-I) and reach higher concentrations in genital tract secretions (B-III).</li><li class="elsevierStyleListItem" id="lsti0455">•If the results of resistance testing are not available, it is preferable to begin with a regimen based on DTG or boosted DRV until the results become available (A-II).</li><li class="elsevierStyleListItem" id="lsti0460">•If is ART is initiated, it should be administered indefinitely (A-I).</li></ul>2. Infection by HIV-2Recommendations<ul class="elsevierStyleList" id="lis0225"><li class="elsevierStyleListItem" id="lsti0465">•The general principles of ART in patients infected by HIV-2 should be the same as those of HIV-1 infection (A-III). Clinical monitoring is recommended. The CD4+ lymphocyte count should be determined every 3–6 month, as should HIV-2 PVL, if available.</li><li class="elsevierStyleListItem" id="lsti0470">•The preferred regimen for initial ART in these patients is the combination of 2 NRTI and 1 INSTI or a boosted PI (A-III).</li><li class="elsevierStyleListItem" id="lsti0475">•The use of NNRTI, MVC, or ENF is not indicated for the treatment of HIV-2 infection (A-I).</li></ul>3. PregnancyA specific GESIDA document is available. The most important recommendations are summarized below.Recommendations<ul class="elsevierStyleList" id="lis0230"><li class="elsevierStyleListItem" id="lsti0480">•All pregnant women must undergo HIV serology testing (A-I). If the result is negative, testing must be repeated during the third trimester (A-II).</li><li class="elsevierStyleListItem" id="lsti0485">•Pre-pregnancy counseling must form part of health care for HIV-infected women of childbearing age and should include a recommendation for ART so that the woman can become pregnant with an undetectable PVL (A-II).</li><li class="elsevierStyleListItem" id="lsti0490">•ART is indicated in all pregnant women, irrespective of CD4+ T-lymphocyte count and PVL, in order to ensure that PVL remains undetectable for as long as possible during pregnancy, especially during the third trimester and at delivery (A-I).</li><li class="elsevierStyleListItem" id="lsti0495">•The choice of specific antiretroviral drugs should be based on resistance studies, drug safety, and ease of adherence. If there are no resistance mutations, the regimen of choice is TDF or ABC+3TC or FTC+LPV/r or ATV/r (A-I) or DRV/r (A-II) or RAL (A-II); if resistance mutations are detected, patients can receive any of the “preferential” and “alternative” antiretroviral drugs after a personalized evaluation (A-III).</li><li class="elsevierStyleListItem" id="lsti0500">•Intrapartum intravenous administration of ZDV is only indicated in women whose PVL is >1000copies/mL or unknown at the time of delivery, irrespective of any previous ART received (A-I).</li><li class="elsevierStyleListItem" id="lsti0505">•Elective cesarean delivery is indicated at week 38 in women with a pre-labor PVL of >1000copies/mL (A-II).</li><li class="elsevierStyleListItem" id="lsti0510">•Mothers cannot breastfeed. Adapted formula food must be used (A-I).</li></ul>4. Comorbid conditions(a) Initial ART in patients with opportunistic infections other than tuberculosisRecommendations<ul class="elsevierStyleList" id="lis0235"><li class="elsevierStyleListItem" id="lsti0515">•In most opportunistic infections (except tuberculosis and cryptococcal meningitis), ART should be started as soon as possible (preferably within the first 15 days after starting treatment for the infection) (A-II).</li><li class="elsevierStyleListItem" id="lsti0520">•Patients with Pneumocystis jiroveci pneumonia who are not receiving ART, should start ART during the 2 weeks following the diagnosis of Pneumocystis jiroveci pneumonia (A-I).</li><li class="elsevierStyleListItem" id="lsti0525">•In patients with cryptococcal meningitis, initiation of ART should be deferred for 5 weeks because of the greater risk of death associated with early initiation (especially in patients with <5cells/μL in CSF or increased intracranial pressure) (A-I).</li></ul>(b) ART and tuberculosisTreatment of tuberculosis in HIV-infected adults was the subject of a consensus document from GESIDA/National AIDS Plan, which is available for consultation.Optimal timing of ARTRecommendations<ul class="elsevierStyleList" id="lis0240"><li class="elsevierStyleListItem" id="lsti0530">•ART should always be started during treatment of tuberculosis, irrespective of the CD4+ T-lymphocyte count, since it reduces the risk of death (A-I).</li><li class="elsevierStyleListItem" id="lsti0535">•The optimal time for initiating ART depends on the CD4+ T-lymphocyte count. If the CD4+ T-lymphocyte count is <50cells/μL, ART should be started as soon as possible, after verifying tolerance to anti-tuberculosis treatment, but not later than the first 2 weeks (A-I). If the CD4+ T-lymphocyte count is >50cells/μL, initiation of ART can be delayed until the intense phase of anti-tuberculosis treatment has been completed (8 weeks). This approach reduces the risk of adverse effects and the development of immune reconstitution inflammatory syndrome (IRIS) without compromising survival (A-I).</li></ul>ART regimensRecommendations<ul class="elsevierStyleList" id="lis0245"><li class="elsevierStyleListItem" id="lsti0540">•Choice of NRTI: No significant interactions or evidence of toxicity have been found between antituberculosis drugs and NRTI. Therefore, ABC, TDF, 3TC, and FTC can be used in these patients with no added risks (A-I). However, a relevant interaction could occur between TAF and the rifamycins, with a decrease in absorption and in the plasma concentration of TAF, since TAF is transported by glycoprotein P (P-gp) and the rifamycins induce the activity of this protein.</li><li class="elsevierStyleListItem" id="lsti0545">•Choice of the third drug. Since most experience and the best results have been obtained with EFV, this is the antiretroviral drug of choice (A-I). The dose of EFV is standard for all patients (600mg/d), irrespective of body weight and with no need to increase to 800mg/d (A-I).</li><li class="elsevierStyleListItem" id="lsti0550">•Alternative third drugs. Based on experience or sufficient evidence, the alternative regimens that can be recommended include NVP at habitual doses (A-II) and RAL at 800mg/12h (A-II), although 400mg/12h has proven to be efficacious, as has MVC at 600mg/12h (A-III). Despite the absence of clinical data, the results of pharmacokinetic studies show that DTG can be administered at 50mg/12hours (A-III).</li><li class="elsevierStyleListItem" id="lsti0555">•Drugs that cannot be used. The other NNRTI (RPV and ETV), PI (whether boosted or not with ritonavir or cobicistat), and EVG should not be co-administered with rifampicin. In the exceptional case of a PI being the only option for ART, rifampicin should be replaced by rifabutin and the corresponding adjustment in drug doses should be made (A-II).</li></ul>Immune reconstitution inflammatory syndrome (IRIS)Recommendations<ul class="elsevierStyleList" id="lis0250"><li class="elsevierStyleListItem" id="lsti0560">•If the patient develops IRIS, neither ART nor anti-tuberculosis medication should be interrupted (A-III).</li><li class="elsevierStyleListItem" id="lsti0565">•The symptoms of IRIS can by managed by adding non-steroidal anti-inflammatory drugs in mild to moderate cases (A-III) or corticosteroids in moderate to severe forms (A-II).</li></ul>(c) Renal insufficiencyFor a complete overview of renal disorders in HIV-infected patients, please consult the consensus document drafted by GESIDA, the SEN, and the SEQC.Recommendations<ul class="elsevierStyleList" id="lis0255"><li class="elsevierStyleListItem" id="lsti0570">•It is necessary to adjust the dose of NRTI, except for ABC (A-II).</li><li class="elsevierStyleListItem" id="lsti0575">•No dose adjustment is required for NNRTI, PI, ENF, RAL, or DTG (A-II).</li><li class="elsevierStyleListItem" id="lsti0580">•The dose of MVC should be adjusted if it is used in combination with potent CYP3A4 inhibitors such as PI (except TPV/r), ketoconazole, itraconazole, clarithromycin, and telithromycin (A-II).</li><li class="elsevierStyleListItem" id="lsti0585">•Co-formulations of antiretroviral drugs are not advised in patients with significant renal insufficiency. The co-formulation EVG/c/FTC/TDF should not be used in patients with an eGFR <70mL/min. The co-formulations EFV/FTC/TDF, RPV/EFV/TDF, and DTG/ABC/3TC should not be used in patients with eGFR <50mL/min. The co-formulation EVG/c/FTC/TAF should not be used in patients with eGFR <30mL/min. In these cases, antiretroviral drugs should be administered separately and the appropriate adjustments made (B-III).</li><li class="elsevierStyleListItem" id="lsti0590">•In patients with renal insufficiency (any stage), kidney function should be closely monitored and nephrotoxic drugs avoided (A-III).</li><li class="elsevierStyleListItem" id="lsti0595">•In patients with advanced chronic renal insufficiency, the dose should be adjusted according to the recommendations of the summary of product characteristics, taking into account possible drug interactions, which are more common and more dangerous in this situation (A-II). In the absence of contraindications, the combination of ABC+3TC (adjusted for eGFR) with an NNRTI or a non-boosted INSTI (DTG or RAL) or DRV/r can be used (A-III).</li></ul>(d) Liver disease (HCV, HBV, cirrhosis)Both SEIMC and AEEH recently drafted guidelines for the management of hepatitis C. Please consult the guidelines for more detailed information.Initiation of ARTRecommendations<ul class="elsevierStyleList" id="lis0260"><li class="elsevierStyleListItem" id="lsti0600">•Patients co-infected with HCV should initiate ART irrespective of their CD4+ T lymphocyte count (A-I).</li><li class="elsevierStyleListItem" id="lsti0605">•In patients who require treatment for hepatitis C, it is generally preferable to initiate ART before starting treatment for HCV infection A-III).</li><li class="elsevierStyleListItem" id="lsti0610">•Patients co-infected with HBV for whom treatment of HBV infection is indicated should initiate ART containing TDF or TAF and FTC or 3TC (A-I).</li></ul>Choice of antiretroviral drugsRecommendations<ul class="elsevierStyleList" id="lis0265"><li class="elsevierStyleListItem" id="lsti0615">•Any antiretroviral drug can be used in patients with chronic liver disease and normal liver function, including patients with cirrhosis (Child-Pugh, class A) (A-I), although it seems reasonable to avoid dideoxynucleoside drugs and nevirapine (A-III).</li><li class="elsevierStyleListItem" id="lsti0620">•In patients with mild or moderate hepatocellular insufficiency (Child–Pugh stage A or B), INSTI do not require dose adjustments and are the drugs of choice (A-I). Boosted PI have a greater therapeutic margin than NNRTI (A-II). In patients with Child–Pugh stage C disease, RAL does not require dose adjustment and ATV/r and FPV/r (with the dose of FPV/r adjusted) are safe (A-II).</li><li class="elsevierStyleListItem" id="lsti0625">•With the exception of sofosbuvir, currently used DAA (simeprevir, daclatasvir, ledipasvir, paritaprevir, ombitasvir, dasabuvir, elbasvir and grazoprevir) present significant pharmacokinetic interactions with antiretroviral drugs that may require doses to be adjusted or coadministration to be contraindicated (A-I).</li><li class="elsevierStyleListItem" id="lsti0630">•An updated pharmacologic interaction software package should be used before prescribing a DAA-containing regimen in a patient on ART (A-III).</li></ul>(e) CancerPlease refer to the relevant GESIDA documents for complete information on cancer in HIV-infected patients.Recommendations<ul class="elsevierStyleList" id="lis0270"><li class="elsevierStyleListItem" id="lsti0635">•ART is an essential component of the treatment of HIV-infected patients with Kaposi sarcoma or non-Hodgkin lymphoma (A-II).</li><li class="elsevierStyleListItem" id="lsti0640">•Patients with other types of cancer who are not receiving ART should initiate therapy as soon as possible (A-II).</li><li class="elsevierStyleListItem" id="lsti0645">•Given its pharmacological characteristics, excellent tolerance, and minimal interactions, RAL should be the antiretroviral drug of choice, where possible, in patients receiving chemotherapy (A-III). DTG can be considered an alternative in cases of resistance to RAL (C-III).</li></ul>Comparative cost of the different antiretroviral combinationsTogether with the present consensus document, GESIDA has published a pharmaco-economic study in which the cost-effectiveness of the recommended preferred and alternative regimens is evaluated. Please consult the relevant document.Recommendation<ul class="elsevierStyleList" id="lis0275"><li class="elsevierStyleListItem" id="lsti0650">•Cost-effectiveness criteria should be taken into account when deciding on initial ART (A-III).</li></ul>Conflicts of interestThis consensus document was drafted without grant aid or other funding, whether collective or individual, from any private institutions. The conflicts of interest not associated with this document declared by the Members of the Editorial Board are set out below.Antonio Antela has received payment for participating in consultancy meetings, acting as a researcher in clinical trials, and speaking at meetings or symposia from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV Healthcare.José R. Arribas has acted as a consultant for AbbVie Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, Tobira, and ViiV Healthcare. He has received grant support for clinical research from Janssen, Merck Sharp & Dohme, and Gilead Sciences, and payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Victor Asensi has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV Healthcare and has received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare. He has also received research grants from Janssen.Juan Berenguer has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead, Janssen, Janssen Therapeutics, Merck Sharp & Dohme, and ViiV Health care. He has received clinical research grant support from Bristol-Myers Squibb, Merck Sharp & Dohme, and ViiV Health care and payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Health care.José R. Blanco has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare. He has received clinical research grant support from Bristol-Myers Squibb y Gilead Sciences, and payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.José Luis Casado has acted as a consultant for AbbVie and ViiV Healthcare. He has received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare and has received clinical research grants from Janssen, Gilead Sciences, and ViiV Healthcare.Bonaventura Clotet has acted as a consultant, participated in clinical trials, and given paid talks for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Manuel Crespo has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare and has received clinical research grants from Gilead Sciences and ViiV Healthcare. He has received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare and for developing training presentations from Bristol-Myers Squibb, Gilead Sciences, and ViiV Healthcare.Pere Domingo has acted as a consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV Healthcare. He has received clinical research grant support from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV Healthcare and payment for talks from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV Healthcare.Carlos Dueñas has acted as a consultant for Gilead Sciences and Janssen. He has received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.José M. Gatell has acted as a consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, and ViiV Healthcare. He has received clinical research grant support from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, and ViiV Healthcare and payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, and ViiV Healthcare.Juan Luis Gómez Sirvent has acted as a consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb and Merck Sharp & Dohme. He has also participated in clinical trials and studies sponsored by AbbVie, Boehringer Ingelheim, Gilead Sciences, Janssen, and ViiV Healthcare and has received payment for talks from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Juan González García has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare. Has received clinical research grant support and payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare. He has also received financial support to attend scientific meetings from Bristol-Myers Squibb, Gilead Sciences and Janssen.José Antonio Iribarren has acted as a consultant for AbbVie and Janssen, and has received clinical research grant support from AbbVie, Bristol-Myers Squibb, Gobierno Vasco, FIPSE, and FISS. He has also received financial support to attend scientific meetings from AbbVie, Gilead Sciences, Janssen, and ViiV, and has participated in training activities, talks, and symposia sponsored by AbbVie, Bristol-Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, Novartis, Janssen, Pfizer, and ViiV.José López Aldeguer has acted as a consultant for Gilead Sciences, Janssen, and ViiV Healthcare. He has received clinical research grant support from ViiV Healthcare and has received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Juan C. López Bernaldo de Quirós has acted as a consultant for Janssen and ViiV Healthcare and has received lecture fees from AbbVie, Bristol-Myers Squibb, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Luis F. López Cortés has received unrestricted research funding, consultancy fees, and lecture fees from and have served on the advisory boards of Abbvie, Bristol-Myers Squibb, Gilead Sciences, Janssen-Cilag, Merck Sharp & Dohme, and ViiV Healthcare.Juan E. Losa has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare and has received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Fernando Lozano has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck-Sharp & Dohme, and ViiV Healthcare and has received payment for training sessions from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck-Sharp & Dohme, and ViiV Healthcare.Josep Mallolas has acted as a consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, and ViiV Healthcare and has received research grants from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, and ViiV Healthcare. He has also received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, and ViiV Healthcare.Ana Mariño has received grant aid for attendance at conferences and meetings from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV Healthcare.Esteban Martínez has acted as a consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck Sharp & Dohme, Theratechnologies, and ViiV Healthcare. He has also received research grants from Merck Sharp & Dohme and payment for training sessions from AbbVie, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, MerckSharp & Dohme, and ViiV Healthcare.José M. Miró has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, Novartis, and Sanofi and has received clinical research grant support from Cubist, Gilead Sciences, Merck Sharp & Dohme, Novartis, Fondo de Investigaciones Sanitarias (FIS) del Instituto de Salud Carlos III (Madrid), Fundación para la Investigación y Prevención del Sida en España (FIPSE, Madrid), Ministerio de Sanidad, Servicios Sociales e Igualdad (MSSSI, Madrid), National Institutes of Health (NIH, Bethesda, MA, USA), and NEAT. He has also received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, Novartis, and ViiV Healthcare.Santiago Moreno has acted as a consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and Roche Pharma, and has received clinical research grant support from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and Roche Pharma. He has also received payment for talks from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and Roche Pharma.Rosario Palacios has acted as a consultant for Bristol-Myers Squibb, Gilead Sciences, and Janssen and has received payment for talks from Bristol-Myers Squibb, Merck Sharp & Dohme, Janssen, Gilead Sciences, and ViiV-Healthcare.Juan Pasquau has received payment during the last 3 years for scientific consultancy services from AbbVie, Bristol-Myers Squibb, Janssen, and ViiV Healthcare and for lectures and other training activities from Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare. He has also received research grants from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.José A. Pérez Molina has acted as a consultant for Bristol-Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, and ViiV Healthcare and has received payment for talks from Bristol-Myers Squibb, Merck Sharp & Dohme, and ViiV Healthcare.Juan A. Pineda declares that he has received payment for consultancy services from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen, and Merck Sharp & Dohme, and research grants from Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen, Merck Sharp & Dohme, Roche Pharma, and ViiV Healthcare. He has also received payment for talks from Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen, Merck Sharp & Dohme, Roche Pharma, and ViiV Healthcare.Daniel Podzamczer has received research grants and/or consultancy fees and/or lecture fees from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Rosa Polo declares that she has not received any grant aid or subsidies associated with this document.Joaquín Portilla has acted as a consultant for AbbVie, Gilead Sciences, and Janssen; he has received payment for talks from AbbVie, Bristol Myers-Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Eva Poveda has received grants for attending conferences and scientific meetings from Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare. She has received payment for talks from Janssen Cilag and Merck Sharp & Dohme and grants for developing research projects and biomedical training activities from Gilead Sciences and Janssen.Federico Pulido has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare and has received payment for talks from Abbott Laboratories, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Antonio Rivero has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, and ViiV Healthcare. He has received clinical research grant support from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, and ViiV Healthcare and payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Merck Sharp & Dohme, and ViiV Healthcare.Rafael Rubio has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, and Janssen and has received payment for talks from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, Roche Phasma, and ViiV Healthcare.Jesús Santos has acted as a consultant for Bristol-Myers Squibb, Gilead Sciences, Janssen, and ViiV-Healthcare and has received fees for educational talks from Bristol-Myers Squibb, Merck Sharp & Dohme, Janssen, Gilead Sciences, and ViiV-Healthcare.José Sanz Moreno has participated in clinical trials sponsored by Bristol-Myers Squibb, and ViiV Healthcare. He has received payment for consultancy work and preparing training presentations for AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Jesús Sanz Sanz has acted as a consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare. He has received payment for talks from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare, and for preparing training presentations from ViiV Healthcare.María Jesús Téllez has acted as a consultant for AbbVie, Bristol-Myers Squibb, Gilead Sciences, and Janssen and has received payment for talks from Gilead Sciences and Janssen.Javier de la Torre has acted as a consultant for Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen, Merck Sharp & Dohme, and ViiV Healthcare and has received payment for talks from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen, Merck Sharp & Dohme, and ViiV Healthcare.Montserrat Tuset has received clinical research grant support from Bristol-Myers Squibb, Gilead Sciences, Janssen, and Merck Sharp & Dohme and payment for talks from Gilead Sciences, Janssen, Merck Sharp & Dohme, and ViiV Healthcare." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1063872" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1011993" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1063871" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1011992" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Clinical and laboratory evaluation as a guide for ART" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical evaluation" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Laboratory tests" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "CD4+ lymphocytes" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Plasma viral load" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Plasma concentration of antiretroviral drugs" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Resistance of HIV-1 to antiretroviral drugs" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Determination of the HLA-B*5701 allele" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Determination of tropism" ] ] ] 6 => array:3 [ "identificador" => "sec0055" "titulo" => "Initial antiretroviral therapy" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "When should ART be initiated?" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Which combination of antiretroviral drugs should be used?" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "1. NRTI" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "2. NNRTI" ] 4 => array:2 [ "identificador" => "sec0080" "titulo" => "3. PI boosted with ritonavir or cobicistat (PI/r or PI/c)" ] 5 => array:2 [ "identificador" => "sec0085" "titulo" => "4. INSTI" ] ] ] 7 => array:3 [ "identificador" => "sec0090" "titulo" => "Switching ART in patients with an undetectable PVL" "secciones" => array:22 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Remarks on the new regimen" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Virological considerations when switching efficacious ART" ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "1. Switching drugs from the same family" ] 3 => array:2 [ "identificador" => "sec0110" "titulo" => "Switching from ABC/3TC to TDF/FTC" ] 4 => array:2 [ "identificador" => "sec0115" "titulo" => "Switching from TDF to ABC" ] 5 => array:2 [ "identificador" => "sec0120" "titulo" => "Switching from TDF/FTC to TAF/FTC" ] 6 => array:2 [ "identificador" => "sec0125" "titulo" => "Switching from EFV/TDF/FTC to RPV/TDF/FTC" ] 7 => array:2 [ "identificador" => "sec0130" "titulo" => "Switching from RPV/TDF/FTC to RPV/TAF/FTC" ] 8 => array:2 [ "identificador" => "sec0135" "titulo" => "Switching from EFV or NVP + 2 NRTI to EFV/TDF/FTC" ] 9 => array:2 [ "identificador" => "sec0140" "titulo" => "Switching from ATV/r + ABC/3TC to unboosted ATV + ABC/3TC" ] 10 => array:2 [ "identificador" => "sec0145" "titulo" => "Switching from ATV/r or DRV/r to ATV/c or DRV/c" ] 11 => array:2 [ "identificador" => "sec0150" "titulo" => "Switching from ATV/r + TDF/FTC to unboosted ATV + ABC/3TC" ] 12 => array:2 [ "identificador" => "sec0155" "titulo" => "2. Switching to antiretroviral drugs from a different family" ] 13 => array:2 [ "identificador" => "sec0160" "titulo" => "Switching from TDF to RAL" ] 14 => array:2 [ "identificador" => "sec0165" "titulo" => "Switching from EFV to RAL" ] 15 => array:2 [ "identificador" => "sec0170" "titulo" => "Switching from TDF/FTC + EFV or NVP to EVG/c/FTC/TDF" ] 16 => array:2 [ "identificador" => "sec0175" "titulo" => "Switching from a boosted PI to EFV/FTC/TDF" ] 17 => array:2 [ "identificador" => "sec0180" "titulo" => "Switching from boosted PI to RPV/FTC/TDF" ] 18 => array:2 [ "identificador" => "sec0185" "titulo" => "Switching from boosted PI to RAL" ] 19 => array:2 [ "identificador" => "sec0190" "titulo" => "Switching from boosted PI to EVG/c/FTC/TDF" ] 20 => array:3 [ "identificador" => "sec0195" "titulo" => "3. Dual therapy with 3TC and ATV/r, DRV/r or LPV/r" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0200" "titulo" => "Switching from 2 NRTI plus ATV/r, DRV/r, or LPV/r to 3TC plus ATV/r, DRV/r, or LPV/r" ] ] ] 21 => array:2 [ "identificador" => "sec0205" "titulo" => "4. Monotherapy with PI/r" ] ] ] 8 => array:2 [ "identificador" => "sec0210" "titulo" => "Failure of ART" ] 9 => array:3 [ "identificador" => "sec0215" "titulo" => "Factors affecting the success of ART" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0220" "titulo" => "1. Adherence" ] 1 => array:3 [ "identificador" => "sec0225" "titulo" => "2. Tolerability and adverse effects" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0230" "titulo" => "(a) Immediate adverse effects" ] 1 => array:2 [ "identificador" => "sec0235" "titulo" => "(b) Late adverse effects" ] ] ] 2 => array:2 [ "identificador" => "sec0240" "titulo" => "3. Drug interactions" ] ] ] 10 => array:3 [ "identificador" => "sec0245" "titulo" => "Special situations" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0250" "titulo" => "1. Acute HIV infection" ] 1 => array:2 [ "identificador" => "sec0255" "titulo" => "2. Infection by HIV-2" ] 2 => array:2 [ "identificador" => "sec0260" "titulo" => "3. Pregnancy" ] 3 => array:3 [ "identificador" => "sec0265" "titulo" => "4. Comorbid conditions" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0270" "titulo" => "(a) Initial ART in patients with opportunistic infections other than tuberculosis" ] 1 => array:2 [ "identificador" => "sec0275" "titulo" => "(b) ART and tuberculosis" ] ] ] 4 => array:2 [ "identificador" => "sec0280" "titulo" => "Optimal timing of ART" ] 5 => array:2 [ "identificador" => "sec0285" "titulo" => "ART regimens" ] 6 => array:3 [ "identificador" => "sec0290" "titulo" => "Immune reconstitution inflammatory syndrome (IRIS)" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0295" "titulo" => "(c) Renal insufficiency" ] 1 => array:2 [ "identificador" => "sec0300" "titulo" => "(d) Liver disease (HCV, HBV, cirrhosis)" ] ] ] 7 => array:2 [ "identificador" => "sec0305" "titulo" => "Initiation of ART" ] 8 => array:3 [ "identificador" => "sec0310" "titulo" => "Choice of antiretroviral drugs" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0315" "titulo" => "(e) Cancer" ] ] ] ] ] 11 => array:2 [ "identificador" => "sec0320" "titulo" => "Comparative cost of the different antiretroviral combinations" ] 12 => array:2 [ "identificador" => "sec0325" "titulo" => "Conflicts of interest" ] 13 => array:2 [ "identificador" => "xack360045" "titulo" => "Acknowledgments" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1011993" "palabras" => array:7 [ 0 => "Antiretroviral therapy" 1 => "HIV infection" 2 => "AIDS" 3 => "Consensus document" 4 => "Recommendations" 5 => "GESIDA" 6 => "Spanish National AIDS Plan" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1011992" "palabras" => array:7 [ 0 => "Tratamiento antirretroviral" 1 => "Infección por VIH" 2 => "Sida" 3 => "Documento de consenso" 4 => "Recomendaciones" 5 => "GESIDA" 6 => "Plan Nacional sobre el Sida" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Antiretroviral therapy (ART) is recommended for all patients infected by HIV-1. The objective of ART is to achieve an undetectable plasma viral load (PVL). Initial ART should be based on a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors (tenofovir in either of its two formulations plus emtricitabine or abacavir plus lamivudine) and another drug from a different family. Four of the recommended regimens, all of which have an integrase inhibitor as the third drug (dolutegravir, elvitegravir boosted with cobicistat or raltegravir), are considered preferential, whereas a further 3 regimens (based on elvitegravir/cobicistat, rilpivirine, or darunavir boosted with cobicistat or ritonavir) are considered alternatives. We present the reasons and criteria for switching ART in patients with an undetectable PVL and in those who present virological failure, in which case salvage ART should include 3 (or at least 2) drugs that are fully active against HIV. We also update the criteria for ART in specific situations (acute infection, HIV-2 infection, pregnancy) and comorbidities (tuberculosis or other opportunistic infections, kidney disease, liver disease and cancer)." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Se recomienda tratamiento antirretroviral (TAR) a todas las personas con infección por VIH-1. El objetivo del TAR es lograr una carga viral plasmática (CVP) indetectable. El TAR inicial debe ser una combinación de 3 fármacos, que incluya 2 inhibidores de la transcriptasa inversa análogos de nucleósidos (tenofovir en cualquiera de sus dos formas más emtricitabina o abacavir más lamivudina) y otro de distinta familia. Cuatro de las pautas recomendadas, todas las cuales tienen un inhibidor de la integrasa como tercer fármaco (dolutegravir, elvitegravir potenciado con cobicistat o raltegravir), se consideran preferentes, mientras que otras tres, (basadas en elvitegravir/cobicistat, rilpivirina o darunavir potenciado con cobicistat o ritonavir), como alternativas. Se exponen las causas y criterios para cambiar el TAR en los pacientes con carga viral plasmática indetectable así como en los que presentan fracaso virológico, en cuyo caso el TAR de rescate debe incluir 3 (o al menos 2) fármacos plenamente activos frente al VIH. Se actualizan los criterios específicos del TAR en situaciones especiales (infección aguda, infección por VIH-2, embarazo) o comorbilidades (tuberculosis u otras enfermedades oportunistas, enfermedad renal, hepatopatías y neoplasias)." ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "See writing committee in <a class="elsevierStyleCrossRef" href="#sec0330">Appendix A</a>." "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "etiqueta" => "Appendix A" "identificador" => "sec0330" "apendiceSeccion" => array:1 [ 0 => array:3 [ "apendice" => "Antonio Rivero1, Rosa Polo2, José López Aldeguer3, Fernando Lozano4, Antonio Antela5, José Ramón Arribas6, Víctor Asensi7, Juan Berenguer8, José Ramón Blanco9, José Luis Casado10, Bonaventura Clotet11, Manuel Crespo12, Pere Domingo13, Carlos Dueñas14, José María Gatell15, Juan Luis Gómez-Sirvent16, Juan González-García17, José Antonio Iribarren18, Juan Carlos López Bernaldo de Quirós19, Luis Fernando López Cortés20, Juan Emilio Losa21, Josep Mallolas22, Ana Mariño23, Esteban Martínez24, José M. Miró25, Santiago Moreno26, Rosario Palacios27, Juan Pasquau28, Juan Antonio Pineda29, Daniel Podzamczer30, Joaquín Portilla31, Eva Poveda32, Federico Pulido33, Rafael Rubio34, Jesús Santos35, José Sanz Moreno36, Jesús Sanz Sanz37, María Jesús Téllez38, Javier de la Torre39, Montserrat Tuset40, José A. Pérez Molina41. 1Hospital Universitario Reina Sofía/IMIBIC, Córdoba; 2Secretaría del Plan Nacional sobre el Sida, Ministerio de Sanidad, Servicios Sociales e Igualdad; 3Hospital Universitario La Fe, IIS La Fe, Valencia; 4Hospital Universitario Virgen de Valme, Sevilla; 5Hospital Clínico Universitario, Santiago de Compostela; 6Hospital Universitario La Paz-IdiPAZ, Madrid; 7Hospital Universitario Central de Asturias, Oviedo; 8Hospital General Universitario Gregorio Marañón, Madrid 9Hospital San Pedro-CIBIR, Logroño; 10Hospital Ramón y Cajal-IRYCIS, Madrid; 11Hospital Germans Trias i Pujol, Badalona; 12Complexo Hospitalario Universitario de Vigo; 13Hospitals Universitaris Arnau de Vilanova i Santa Maria, Universitat de Lleida, IRB-Lleida, Lleida; 14Hospital Universitario de Valladolid (HCUV); 15Hospital Clínic/IDIBAPS, UB, Barcelona; 16Hospital Universitario de Canarias, Santa Cruz de Tenerife; 17Hospital Universitario La Paz/IdiPAZ, Madrid; 18Hospital Universitario Donostia, San Sebastián; 19Hospital General Universitario Gregorio Marañón, Madrid; 20Hospital Universitario Virgen del Rocío, Sevilla; 21Hospital Universitario Fundación Alcorcón, Alcorcón (Madrid); 22Hospital Clínic/IDIBAPS, UB, Barcelona; 23Complejo Hospitalario Universitario de Ferrol; 24Hospital Clínic/IDIBAPS, UB, Barcelona; 25Hospital Clínic/IDIBAPS, UB, Barcelona; 26Hospital Ramón y Cajal/IRYCIS, Madrid; 27Hospital Universitario Virgen de la Victoria, Málaga; 28Hospital Virgen de las Nieves, Granada; 29Hospital Universitario Virgen de Valme, Sevilla; 30IDIBELL-Hospital Universitario de Bellvitge, L’Hospitalet, Barcelona; 31Hospital General Universitario, Alicante; 32Complejo Hospitalario Universitario, A Coruña; 33Hospital Universitario 12 de Octubre, Madrid; 34Hospital Universitario 12 de Octubre, Madrid; 35Hospital Universitario Virgen de la Victoria, Málaga; 36Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid; 37Hospital Universitario de la Princesa, Madrid; 38Hospital Clínico San Carlos, Madrid; 39Hospital Costa del Sol, Marbella; 40Hospital Clínic/IDIBAPS, UB, Barcelona; 41Hospital Ramón y Cajal/IRYCIS, Madrid." "titulo" => "Writing committee:" "identificador" => "sec0335" ] ] ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "ABC, abacavir; ATV/r/c, atazanavir boosted with ritonavir or cobicistat; c, cobicistat; DTG, dolutegravir; DRV/r/c, darunavir boosted with ritonavir or cobicistat; DRV/r, darunavir boosted with ritonavir; eGFR, estimated glomerular filtration rate; EVG/c, elvitegravir boosted with cobicistat; EFV, efavirenz; FTC, emtricitabine; INSTI, integrase inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitors; RAL, raltegravir; RPV, rilpivirine; TFV, tenofovir in either of its 2 formulations; TDF, tenofovir-disoproxil fumarate; TAF, tenofovir-alafenamide; 3TC, lamivudine." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Third drug \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Regimen<a class="elsevierStyleCrossRef" href="#tblfn0005">†</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Remarks<a class="elsevierStyleCrossRef" href="#tblfn0010">‡</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Preferred. Regimens that can be applied to most patients and whose efficacy in randomized clinical trials is superior to that of others or that, while showing non-inferiority, have additional advantages in terms of tolerance and toxicity or have a low risk of drug interactions.</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">INSTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ABC/3TC/DTG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ABC is contraindicated in patients with a positive HLA-B5701 test result. When ABC is prescribed, the necessary measures should be taken to minimize all modifiable cardiovascular risk factors. - Few data for patients with CD4+ <200cells/μL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TFV<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>/FTC+DTG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Few data for patients with CD4+ <200cells/μL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TFV<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>/FTC+RAL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TAF/FTC/EVG/c<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Few data for patients with CD4+ <200cells/μL - Greater potential for interactions than other INSTI-based regimens \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Alternatives. Efficacious regimens that are not considered preferred because their efficacy was lower than that of preferred regimens in clinical trials or because they have potential drawbacks or restricted indications. However, they may be the regimen of choice in subgroups of patients or in special cases.</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NNRTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TFV<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>/FTC/RPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Not indicated in patients with PVL >100,000copies/mL - Can be regimen of choice in patients with PVL <100,000copies/mL (more efficacious than TDF/FTC/EFV), especially if simplicity is a priority - Few data for patients with CD4+ <200cells/μL - Perform genotyping before hand to rule out NNRTI resistance mutations. - Contraindicated in patients taking proton pump inhibitors. - Must always be taken with food. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boosted PI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TFV<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>/FTC+DRV/r/c<a class="elsevierStyleCrossRef" href="#tblfn0020">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Since sufficient data on this regimen are available for patients with CD4+ <200cells/μL, it can be considered the regimen of choice in very immunodepressed patients, especially when it is necessary to administer a regimen with a high genetic barrier (patients with poor adherence). - Combination of PI/r and TDF increases the risk of nephrotoxicity. - Greater likelihood of interactions than other regimens. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">INSTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TDF/FTC/EVG/c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Few data for patients with CD4+ <200cells/μL. - Greater likelihood of interactions than other INSTI-based regimens. - Not indicated in patients with eGFR <70mL/min. Use with caution in patients with eGFR <90mL/min. - Can be considered a regimen of choice in women (more efficacious than TDF/FTC+ATV/r), especially if simplicity is a priority. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Other possible regimens. These regimens have also demonstrated efficacy; however, either available evidence is considered insufficient or the regimen has drawbacks with respect to regimens considered preferred or alternative</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">INSTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ABC/3TC+RAL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ABC is contraindicated in patients with a positive HLA-B5701 test result. When ABC is prescribed, the necessary measures should be taken to minimize all modifiable cardiovascular risk factors. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NNRTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TDF/FTC/EFV o TAF/FTC+EFV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Avoid in women planning to become pregnant and patients with neuropsychiatric disorders or suicidal ideation. Use with caution in patients who perform dangerous tasks. - Since sufficient data are available on this regimen in patients with CD4+ <200cells/μL, it can be used as the regimen of choice in very immunodepressed patients, especially if simplicity is a priority (if the combination is available as a coformulation). - Perform genotyping before hand to rule out NNRTI resistance mutations. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boosted PI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TFV<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a>/FTC+ATV/r/c<a class="elsevierStyleCrossRef" href="#tblfn0020">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Avoid in patients taking proton pump inhibitors. - Since sufficient data on this regimen are available for patients with CD4+ <200cells/μL, it can be considered the regimen of choice in very immunodepressed patients, especially when it is necessary to administer a regimen with a high genetic barrier (patients with poor adherence). - Combination of PI/r and TDF increases the risk of nephrotoxicity. - Greater likelihood of interactions than other regimens. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ABC/3TC+DRV/r/c<a class="elsevierStyleCrossRef" href="#tblfn0020">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- ABC is contraindicated in patients with a positive HLA-B5701 test result. When ABC is prescribed, the necessary measures should be taken to minimize all modifiable cardiovascular risk factors. - Evaluate potential interactions. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RAL+DRV/r \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Do not use in patients with CD4 <200cells/μL. - Avoid in patients with PVL >100,000copies/mL. - Can be used as an alternative to conventional triple therapy when neither TDF nor ABC can be prescribed. - Greater probability of interactions than other regimens. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1813916.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "†" "nota" => "When available, fixed-dose combinations should be used. There are no data showing that FTC and 3TC can be considered therapeutically equivalent; therefore, use of one or other drug in the regimens selected essentially depends on experience of use in combination with other drugs in the regimen. The clinical trials on which the evidence for each regimen is based are referenced in the text. In drugs from the same family and with the same level of recommendation, the order reflects the preference of the expert panel." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "‡" "nota" => "The remarks reflect aspects that should be taken into consideration when choosing the regimen; they do not aim to be an exhaustive guide to the precautions to be taken when receiving these drugs. Please see the main text and the appropriate Summary of Product Characteristics for more information. Cost and pricing of the therapeutic regimens are addressed elsewhere in these guidelines. The cost-effectiveness of the regimens is analyzed formally in an article published simultaneously with the guidelines." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "*" "nota" => "TFV can be used as TDF or as TAF. Both formulations have shown equivalent efficacy. TDF should not be used if the eGFR is <50ml/min. TAF is preferred in patients with altered renal function or osteoporosis or who are at risk of these conditions. The coformulations TAF/FTC and TAF/FTC/RPV have been approved by the EMA, although at the time of writing, they are not sold in Spain." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "**" "nota" => "DRV and ATV can be boosted with ritonavir or cobicistat. Combination with cobicistat (coformulation) reduces the pill burden. When choosing a booster, it is important to review all possible interactions, as these are not always identical with ritonavir and cobicistat." ] ] ] "descripcion" => array:1 [ "en" => "Recommended combinations of initial ART<a class="elsevierStyleCrossRef" href="#tblfn0005">†</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:2 [ 0 => array:3 [ "identificador" => "bib0015" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Panel de Expertos de GESIDA y Plan Nacional sobre el Sida. Documento de consenso de GESIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (actualización enero 2017). Available from: <a id="intr0005" class="elsevierStyleInterRef" href="http://www.gesida-seimc.org/guias_clinicas.php?mn_MP=406%26mn_MS=407">http://www.gesida-seimc.org/guias_clinicas.php?mn_MP=406&mn_MS=407</a> (accessed 17.02.17)." ] ] ] 1 => array:3 [ "identificador" => "bib0020" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Executive summary of the GESIDA/National AIDS Plan Consensus Document on Antiretroviral Therapy in Adults Infected by the Human Immunodeficiency Virus (Updated January 2016)" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Study Group AIDS (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology and the National AIDS Plan" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2016.02.028" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2016" "volumen" => "34" "paginaInicial" => "439" "paginaFinal" => "451" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27068257" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack360045" "titulo" => "Acknowledgments" "texto" => "The Board of GESIDA and the National AIDS Plan acknowledge the contributions and opinions of Marisa Álvarez, Belén Box, Santiago Cenoz, Inmaculada Clotet, Manuel Cotarelo, Adrián Curran, Pedro Ferrer, Beatriz Hernández-Novoa, Marcela González, Cristina González-Conde, Carmen González-Ortega, José Emilio Martín-Herrero, Julián Olalla, Siria Pablos, Óscar Rincón, Felipe Rodríguez-Alcántara, Nuria Sánchez, Ana Serra, Sergio Serrano, José Verdejo, and Eugenia Vispo." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/0213005X/0000003600000007/v1_201807240423/S0213005X17301313/v1_201807240423/en/main.assets" "Apartado" => array:4 [ "identificador" => "8681" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Documento de consenso" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/0213005X/0000003600000007/v1_201807240423/S0213005X17301313/v1_201807240423/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17301313?idApp=UINPBA00004N"]

Statistics

Consensus statement

Executive summary of the GESIDA/National AIDS Plan Consensus Document on Antiretroviral Therapy in Adults Infected by the Human Immunodeficiency Virus (Updated January 2017)

Resumen ejecutivo del Documento de consenso de GESIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (Actualización enero 2017)

AIDS Study Group (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology and the National AIDS Plan 1

Read

3002

Times
was read the article

968

Total PDF

2034

Total HTML

Share statistics

 array:22 [
  "pii" => "S0213005X17301313"
  "issn" => "0213005X"
  "doi" => "10.1016/j.eimc.2017.04.001"
  "estado" => "S300"
  "fechaPublicacion" => "2018-08-01"
  "aid" => "1690"
  "copyrightAnyo" => "2017"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "pgl"
  "cita" => "Enferm Infecc Microbiol Clin. 2018;36:435-45"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 988
    "formatos" => array:3 [
      "EPUB" => 3
      "HTML" => 565
      "PDF" => 420
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S0213005X17303002"
    "issn" => "0213005X"
    "doi" => "10.1016/j.eimc.2017.10.006"
    "estado" => "S300"
    "fechaPublicacion" => "2018-08-01"
    "aid" => "1758"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "sco"
    "cita" => "Enferm Infecc Microbiol Clin. 2018;36:446-55"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 3072
      "formatos" => array:3 [
        "EPUB" => 1
        "HTML" => 1972
        "PDF" => 1099
      ]
    ]
    "es" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Formaci&#243;n m&#233;dica continuada&#58; Infecciones por micobacterias</span>"
      "titulo" => "Tuberculosis e inmigraci&#243;n"
      "tienePdf" => "es"
      "tieneTextoCompleto" => "es"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "446"
          "paginaFinal" => "455"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Tuberculosis and immigration"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "es" => true
      ]
      "contienePdf" => array:1 [
        "es" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0015"
          "etiqueta" => "Figura 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 1909
              "Ancho" => 2799
              "Tamanyo" => 412561
            ]
          ]
          "descripcion" => array:1 [
            "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tasas de notificaci&#243;n de tuberculosis en inmigrantes y aut&#243;ctonos y proporci&#243;n de TB diagnosticadas en inmigrante del total&#46;Fuente&#58; Framework towards tuberculosis elimination in low-incidence countries&#46; Geneva&#58; World Health Organization&#59; 2014&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Adri&#225;n S&#225;nchez-Montalv&#225;, Fernando Salvador, Daniel Molina-Morant, Israel Molina"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Adri&#225;n"
              "apellidos" => "S&#225;nchez-Montalv&#225;"
            ]
            1 => array:2 [
              "nombre" => "Fernando"
              "apellidos" => "Salvador"
            ]
            2 => array:2 [
              "nombre" => "Daniel"
              "apellidos" => "Molina-Morant"
            ]
            3 => array:2 [
              "nombre" => "Israel"
              "apellidos" => "Molina"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "es"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2529993X18301321"
        "doi" => "10.1016/j.eimce.2018.05.004"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X18301321?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17303002?idApp=UINPBA00004N"
    "url" => "/0213005X/0000003600000007/v1_201807240423/S0213005X17303002/v1_201807240423/es/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S0213005X17302343"
    "issn" => "0213005X"
    "doi" => "10.1016/j.eimc.2017.09.002"
    "estado" => "S300"
    "fechaPublicacion" => "2018-08-01"
    "aid" => "1739"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Enfermedades Infecciosas y Microbiolog&#237;a Cl&#237;nica"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "sco"
    "cita" => "Enferm Infecc Microbiol Clin. 2018;36:431-4"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 1761
      "formatos" => array:3 [
        "EPUB" => 3
        "HTML" => 1507
        "PDF" => 251
      ]
    ]
    "es" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original breve</span>"
      "titulo" => "Prevalencia de especies del complejo <span class="elsevierStyleItalic">Burkholderia cepacia</span> en pacientes con fibrosis qu&#237;stica en Argentina durante el per&#237;odo 2011-2015"
      "tienePdf" => "es"
      "tieneTextoCompleto" => "es"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "431"
          "paginaFinal" => "434"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Prevalence of <span class="elsevierStyleItalic">Burkholderia cepacia</span> complex species in cystic fibrosis patients in Argentina during the period 2011-2015"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "es" => true
      ]
      "contienePdf" => array:1 [
        "es" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Luc&#237;a Cipolla, Florencia Rocca, Claudia Martinez, Lorena Aguerre, Rub&#233;n Barrios, M&#243;nica Prieto"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Luc&#237;a"
              "apellidos" => "Cipolla"
            ]
            1 => array:2 [
              "nombre" => "Florencia"
              "apellidos" => "Rocca"
            ]
            2 => array:2 [
              "nombre" => "Claudia"
              "apellidos" => "Martinez"
            ]
            3 => array:2 [
              "nombre" => "Lorena"
              "apellidos" => "Aguerre"
            ]
            4 => array:2 [
              "nombre" => "Rub&#233;n"
              "apellidos" => "Barrios"
            ]
            5 => array:2 [
              "nombre" => "M&#243;nica"
              "apellidos" => "Prieto"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "es"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2529993X1830131X"
        "doi" => "10.1016/j.eimce.2018.05.003"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X1830131X?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17302343?idApp=UINPBA00004N"
    "url" => "/0213005X/0000003600000007/v1_201807240423/S0213005X17302343/v1_201807240423/es/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Consensus statement</span>"
    "titulo" => "Executive summary of the GESIDA&#47;National AIDS Plan Consensus Document on Antiretroviral Therapy in Adults Infected by the Human Immunodeficiency Virus &#40;Updated January 2017&#41;"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "435"
        "paginaFinal" => "445"
      ]
    ]
    "autores" => array:1 [
      0 => array:2 [
        "autoresLista" => ""
        "autores" => array:1 [
          0 => array:2 [
            "colaborador" => "AIDS Study Group &#40;GESIDA&#41; of the Spanish Society of Infectious Diseases and Clinical Microbiology and the National AIDS Plan"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">1</span>"
                "identificador" => "fn0005"
              ]
            ]
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Resumen ejecutivo del Documento de consenso de GESIDA&#47;Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana &#40;Actualizaci&#243;n enero 2017&#41;"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The complexity and speed of changes of antiretroviral therapy &#40;ART&#41; requires frequent updating of specific guidelines&#46; For the last 18 years&#44; GESIDA and the National AIDS Plan have jointly edited a consensus document on ART in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">1</span></a> The objective of this consensus document&#44; which updates previous recommendations&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">2</span></a> is to provide health professionals who treat HIV-infected adults with up-to-date knowledge on ART and a series of recommendations based on scientific evidence that can act as guidelines in therapeutic decision making&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical and laboratory evaluation as a guide for ART</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical evaluation</span><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0015" class="elsevierStylePara elsevierViewall">A clinical history should be taken for all HIV-infected patients&#46; The history should include an evaluation of the patient&#39;s drug therapy&#44; comorbid conditions&#44; and risk of STI&#46; The patient should also undergo a thorough physical examination&#44; which should be repeated once a year &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">In all newly diagnosed cases&#44; all previous sexual contacts should be evaluated after agreement with the index case and with confidentiality guaranteed &#40;B-III&#41;&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Laboratory tests</span><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Serology testing for HIV should be performed in all cases where HIV infection has not been confirmed and the plasma viral load &#40;PVL&#41; is undetectable &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The initial laboratory workup should include a complete blood count&#44; general biochemistry&#44; and serology testing &#40;Toxoplasma&#44; cytomegalovirus&#44; syphilis&#44; HAV&#44; HBV&#44; and HCV&#41;&#46; Specific tests&#44; including viral load&#44; CD4&#43; T-lymphocyte count&#44; primary resistance to HIV and HLA-B&#42;5701&#44; should also be performed &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">CD4&#43; lymphocytes</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">The absolute number and percentage of CD4&#43; T lymphocytes should be determined before initiating ART&#46; Once therapy has started&#44; these determinations should be made periodically every 3&#8211;6 months to monitor the immune response &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Determinations can be at longer intervals&#44; at the physician&#39;s discretion&#44; in stable patients with suppressed plasma viral load &#40;PVL&#41; and CD4&#43; T-lymphocyte counts &#62;300<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L &#40;C-II&#41;&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Plasma viral load</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">PVL should be determined before initiation of ART and regularly during treatment &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">PVL is the main parameter for evaluating the virological efficacy of ART and for defining virological failure &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">The objectives of virological suppression &#40;VL &#60;50<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#41; should be met both in ART-na&#239;ve patients and in those who have experienced previous therapeutic failure &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">PVL should be determined using a technique with a quantification limit of at least 50<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#46; The same technique should always be used &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">If decisions on therapy are to be taken based on PVL&#44; they should be confirmed with a second determination &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Plasma concentration of antiretroviral drugs</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Determination of the plasma concentration of antiretroviral drugs is not recommended for habitual monitoring of HIV-infected patients &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Determination of the plasma concentration of antiretroviral drugs may be indicated in specific clinical situations &#40;e&#46;g&#46;&#44; risk of pharmacological interactions&#44; organ transplantation&#44; extreme underweight or overweight&#44; pregnancy&#44; and renal or hepatic insufficiency&#41; and to confirm suspected poor adherence to therapy &#40;B-III&#41;&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Resistance of HIV-1 to antiretroviral drugs</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Genotyping of reverse transcriptase and protease to detect HIV resistance mutations should be performed in all patients at diagnosis of infection and before initiating ART if this is deferred &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">The result of the genotyping study should be known before starting ART with non-nucleoside reverse transcriptase inhibitors &#40;NNRTI&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Assessment of baseline integrase resistance mutations is only recommended when there is a high suspicion of transmission of resistance to integrase strand transfer inhibitors &#40;INSTI&#41; &#40;C-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Resistance should be studied by genotyping in all patients in whom virological failure has been confirmed&#46; The study should include integrase resistance mutations if the patient&#39;s regimen includes an INSTI &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Determination of the HLA-B&#42;5701 allele</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">HLA-B&#42;5701 should be determined in all patients before initiating an ART regimen containing ABC &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">ABC should not be prescribed if the result of the HLA-B&#42;5701 determination is positive &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Determination of tropism</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">HIV-1 tropism should be determined before prescribing a CCR5 receptor antagonist &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">HIV-1 tropism should be determined if a regimen containing a CCR5 receptor antagonist fails &#40;A-I&#41;&#46;</p></li></ul></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Initial antiretroviral therapy</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">When should ART be initiated&#63;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">ART should be initiated in all HIV-infected patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Initiation of ART should always be evaluated on an individual basis&#46; Both CD4&#43; T-lymphocyte count and PVL should be determined before initiating ART&#46; Furthermore&#44; the patient should be briefed on the various options available&#44; and the therapeutic regimen should be adapted to lifestyle&#44; comorbid conditions&#44; and possible drug interactions&#46; The risk of poor adherence should also be assessed &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Which combination of antiretroviral drugs should be used&#63;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Initial ART can be a combination of 2 nucleoside reverse transcriptase inhibitors &#40;NRTI&#41; and 1 INSTI&#44; 2 NRTI and 1 NNRTI&#44; or 2 NRTI and 1 boosted protease inhibitor &#40;PI&#41; &#40;A-I&#41;&#46; Preferred antiretroviral drugs are set out in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">1&#46; NRTI</span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">The NRTI combinations of choice for initial regimens are TAF&#47;FTC or TDF&#47;FTC and ABC&#47;3TC &#40;AI&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Co-formulated preparations are recommended &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">The combination TDF&#47;FTC should be avoided in patients with renal insufficiency &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">The combination ABC&#47;3TC should be avoided in patients with a high PVL &#40;&#62;100&#44;000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#41; when combined with an NNRTI or a boosted PI &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">2&#46; NNRTI</span><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">The combinations rilpivirine &#40;RPV&#41;&#47;TAF&#47;FTC and RPV&#47;TDF&#47;FTC are considered preferential in patients with a PVL &#60;100&#44;000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#44; &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">RPV should not be administered to patients with a PVL &#62;100&#44;000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Efavirenz &#40;EFV&#41; is contraindicated during the first trimester of pregnancy&#46; Other options are recommended in women who do not use effective contraception&#46; Similarly&#44; EFV should be avoided in patients with neuropsychiatric disorders or a history of suicidal ideation and in patients who perform dangerous tasks if they present symptoms of somnolence&#44; dizziness&#44; and&#47;or difficulty concentrating &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">3&#46; PI boosted with ritonavir or cobicistat &#40;PI&#47;r or PI&#47;c&#41;</span><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">When it is deemed appropriate to initiate a PI-based regimen&#44; the recommendation is for DRV&#47;r or DRV&#47;c<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TDF&#47;FTC or TAF&#47;FTC &#40;QD&#41; &#40;A-I&#41;&#46; Alternatively&#44; ATV&#47;r or ATV&#47;c<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TDF&#47;FTC or TAF&#47;FTC &#40;QD&#41; could be prescribed &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">ATV and DRV can be boosted interchangeably with ritonavir 100<span class="elsevierStyleHsp" style=""></span>mg or cobicistat 150<span class="elsevierStyleHsp" style=""></span>mg &#40;B-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">The combination DRV&#47;r or DRV&#47;c<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ABC&#47;3TC can also be used&#44; although it has not been formally assessed in a clinical trial &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">DRV&#47;r<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>RAL can be used as an alternative to conventional triple therapy when it is not possible to use TAF&#44; TDF or ABC &#40;B-I&#41;&#46; This regimen should not be used as initial treatment in patients with advanced disease &#40;CD4&#43; T-lymphocyte counts &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L and&#47;or a PVL &#62;100&#44;000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#41; &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">4&#46; INSTI</span><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Dolutegravir &#40;DTG&#41; combined with TDF&#47;FTC or TAF&#47;FTC or coformulated with ABC&#47;3TC&#44; elvitegravir &#40;EVG&#41; coformulated with cobicistat&#47;TAF&#47;FTC &#40;EVG&#47;c&#47;TAF&#47;FTC&#41;&#44; and raltegravir &#40;RAL&#41; combined with TDF&#47;FTC or TAF&#47;FTC are considered preferred regimens for initial treatment &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">The combination EVG&#47;c&#47;TAF&#47;FTC is preferred over EVG&#47;c&#47;TDF&#47;FTC owing to its better tolerability profile and the possibility of administering it with an estimated glomerular filtration rate &#40;eGFR&#41; &#62;30<span class="elsevierStyleHsp" style=""></span>mL&#47;min &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">The combination EVG&#47;c&#47;TDF&#47;FTC can be prescribed as an alternative&#44; although not in patients with an estimated glomerular filtration rate &#60;70<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#41; &#40;A-I&#41;&#46;</p></li></ul></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Switching ART in patients with an undetectable PVL</span><p id="par0270" class="elsevierStylePara elsevierViewall">There are several reasons for changing an efficacious ART regimen &#40;e&#46;g&#46;&#44; tolerance&#44; toxicity&#44; comorbid conditions&#44; drug interactions&#44; and reducing the pill burden or number of daily doses&#41;&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">After switching ART in this context&#44; maintenance of virological suppression and performance of relevant laboratory tests should be evaluated within 3&#8211;6 weeks&#46;</p><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Remarks on the new regimen</span><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0285" class="elsevierStylePara elsevierViewall">In the case of patients with an undetectable PVL&#44; the new regimen should give priority to the drugs recommended as preferential for <span class="elsevierStyleItalic">na&#239;ve</span> patients &#40;A-III&#41;&#46; In specific cases&#44; alternative regimens&#44; or regimens classed as &#8220;other antiretroviral regimens&#8221; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; may be appropriate &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Virological considerations when switching efficacious ART</span><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Switching from a regimen containing 2 NRTI<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>PI&#47;r to one containing 2 NRTI<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 NNRTI&#44; 1 INSTI or unboosted ATV is only possible if the antiviral activity of the 2 NRTI and third drug can be guaranteed &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">1&#46; Switching drugs from the same family</span><p id="par0300" class="elsevierStylePara elsevierViewall">&#40;a&#41; NRTI</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Switching from ABC&#47;3TC to TDF&#47;FTC</span><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">The association between ABC and increased incidence of cardiovascular events is open to debate&#46; This committee cannot make a recommendation on the strength of evidence for switching from ABC&#47;3TC to TDF&#47;FTC &#40;C-I&#41;&#46;</p></li></ul></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Switching from TDF to ABC</span><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0320" class="elsevierStylePara elsevierViewall">The switch from TDF to ABC is a valid option in patients with osteopenia or osteoporosis associated with TDF &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Switching from TDF&#47;FTC to TAF&#47;FTC</span><p id="par0325" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Switching from TDF&#47;FTC to TAF&#47;FTC is virologically safe&#46; This switch is associated with improved bone mineral density and kidney function &#40;A-I&#41;&#46;</p></li></ul></p><p id="par0335" class="elsevierStylePara elsevierViewall">&#40;b&#41; NNRTI</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Switching from EFV&#47;TDF&#47;FTC to RPV&#47;TDF&#47;FTC</span><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall">In patients with adverse central nervous system &#40;CNS&#41; effects caused by EFV&#47;TDF&#47;FTC&#44; the switch to RPV&#47;TDF&#47;FTC is one of the options that can improve the symptoms associated with EFV &#40;A-II&#41;&#46; There are no data in favor of recommending a proactive switch in patients who do not have CNS symptoms or data comparing this switch with a switch to other antiretroviral drugs that do not cause CNS effects&#46;</p></li></ul></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Switching from RPV&#47;TDF&#47;FTC to RPV&#47;TAF&#47;FTC</span><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">Switching from RPV&#47;TDF&#47;FTC or EFV&#47;TDF&#47;FTC to RPV&#47;TAF&#47;FTC is virologically safe&#46; This switch is associated with improved bone mineral density and kidney function &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Switching from EFV or NVP<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2 NRTI to EFV&#47;TDF&#47;FTC</span><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Switching to EFV&#47;TDF&#47;FTC is an option in patients taking ART with EFV and NVP who wish to reduce their pill burden &#40;A-II&#41;&#46;</p></li></ul></p><p id="par0370" class="elsevierStylePara elsevierViewall">&#40;c&#41; Protease inhibitors</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Switching from ATV&#47;r<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ABC&#47;3TC to unboosted ATV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ABC&#47;3TC</span><p id="par0375" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">In patients taking ATV&#47;r<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ABC&#47;3TC&#44; switching to ATV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ABC&#47;3TC is a simplification option when attempting to avoid RTV&#44; owing to hyperbilirubinemia&#44; dyslipidemia&#44; diarrhea&#44; or the risk of interactions with RTV &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Switching from ATV&#47;r or DRV&#47;r to ATV&#47;c or DRV&#47;c</span><p id="par0385" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0390" class="elsevierStylePara elsevierViewall">In patients receiving treatment with ATV&#47;r or DRV&#47;r&#44; switching to ATV&#47;c &#40;A-I&#41; or DRV&#47;c &#40;A-II&#41; is a simplification option that reduces the pill burden&#46; The results of bioequivalence studies lead this Committee to recommend ATV&#47;c or DRV&#47;c interchangeably in contexts that affect ATV&#47;r or DRV&#47;r as a component of triple regimens &#40;see elsewhere in this chapter&#41;&#46; Data on dual regimens or monotherapy are not sufficient to recommend using the drugs interchangeably&#46; Potential interactions with other drugs should always be taken into account&#44; since these are not identical with ritonavir and with cobicistat&#46;</p></li></ul></p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Switching from ATV&#47;r<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TDF&#47;FTC to unboosted ATV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ABC&#47;3TC</span><p id="par0395" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0400" class="elsevierStylePara elsevierViewall">In patients taking ATV&#47;r<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TDF&#47;FTC&#44; switching to ATV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ABC&#47;3TC is an option in those cases where both TDF and RTV have to be avoided &#40;B-I&#41;&#46;</p></li></ul></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">2&#46; Switching to antiretroviral drugs from a different family</span><p id="par0405" class="elsevierStylePara elsevierViewall">&#40;a&#41; Switching from NRTI to INSTI</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Switching from TDF to RAL</span><p id="par0410" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">Switching from TDF to RAL in patients who are also taking a PI&#47;r is also an option in patients with reduced bone mineral density &#40;B-II&#41;&#46;</p></li></ul></p><p id="par0420" class="elsevierStylePara elsevierViewall">&#40;b&#41; Switching from NRTI to MVC</p><p id="par0425" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8226;</span><p id="par0430" class="elsevierStylePara elsevierViewall">Switching to a boosted PI and MVC from regimens that contain 1 boosted PI and 2 NRTI is not virologically safe&#44; although genotyping of proviral DNA shows that the virus is R5-tropic&#46; This switch cannot be recommended &#40;A-I&#41;&#46;</p></li></ul></p><p id="par0435" class="elsevierStylePara elsevierViewall">&#40;c&#41; Switching from NNRTI to INSTI</p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Switching from EFV to RAL</span><p id="par0440" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8226;</span><p id="par0445" class="elsevierStylePara elsevierViewall">Switching from EFV to RAL is an option in patients with CNS adverse events caused by EFV &#40;A-II&#41;&#46; There are no data to recommend a proactive change in patients with no CNS symptoms or data or data comparing this switch with a switch to other antiretroviral drugs that do not cause CNS effects&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8226;</span><p id="par0450" class="elsevierStylePara elsevierViewall">Switching from EFV to RAL is a valid option in patients with dyslipidemia caused by EFV &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Switching from TDF&#47;FTC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EFV or NVP to EVG&#47;c&#47;FTC&#47;TDF</span><p id="par0455" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">&#8226;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Switching from TDF&#47;FTC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EFV or NVP to coformulated EVG&#47;c&#47;FTC&#47;TDF is virologically safe&#46; This change is an option for patients who wish to simplify their current regimen and can improve CNS symptoms caused by EFV &#40;A-I&#41;&#46; There are no data to recommend a proactive change in patients who do not have CNS symptoms&#46; Similarly&#44; there are no data comparing this switch with switches to other drugs that do not cause CNS symptoms&#46;</p></li></ul></p><p id="par0465" class="elsevierStylePara elsevierViewall">&#40;d&#41; Switching from boosted PI to an NNRTI</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Switching from a boosted PI to EFV&#47;FTC&#47;TDF</span><p id="par0470" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">&#8226;</span><p id="par0475" class="elsevierStylePara elsevierViewall">Switching to EFV&#47;FTC&#47;TDF is an option in patients who are taking ART with boosted PI&#46; This approach makes it possible to reduce the daily pill burden&#44; although patients may experience EFV-induced CNS adverse effects &#40;B-I&#41;&#46;</p></li></ul></p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Switching from boosted PI to RPV&#47;FTC&#47;TDF</span><p id="par0480" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8226;</span><p id="par0485" class="elsevierStylePara elsevierViewall">Switching to an ART regimen comprising 2 NRTI and 1 boosted PI to the co-formulation RPV&#47;FTC&#47;TDF is a valid option in patients with gastrointestinal disorders or dyslipidemia&#46; It also enables the daily pill burden to be reduced &#40;A-I&#41;&#46;</p></li></ul></p><p id="par0490" class="elsevierStylePara elsevierViewall">&#40;e&#41; Switching from boosted PI to INSTI</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Switching from boosted PI to RAL</span><p id="par0495" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">&#8226;</span><p id="par0500" class="elsevierStylePara elsevierViewall">Switching to RAL<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2 active NRTI is a valid option for patients with dyslipidemia taking ART with NRTI<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 boosted PI &#40;B-I&#41;&#46;</p></li></ul></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Switching from boosted PI to EVG&#47;c&#47;FTC&#47;TDF</span><p id="par0505" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8226;</span><p id="par0510" class="elsevierStylePara elsevierViewall">Switching from TDF&#47;FTC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ATV&#47;r or DRV&#47;r or LPV&#47;r to EVG&#47;c&#47;TDF&#47;FTC is virologically better than the previous options&#46; This switch is an option for patients who wish to simplify their current regimen and can improve RTV-associated digestive symptoms in some patients &#40;A-I&#41;&#46;</p></li></ul></p><p id="par0515" class="elsevierStylePara elsevierViewall">&#40;f&#41; Switching to EVG&#47;c&#47;FTC&#47;TAF from TDF-containing regimens</p><p id="par0520" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">&#8226;</span><p id="par0525" class="elsevierStylePara elsevierViewall">Switching from EVG&#47;c&#47;FTC&#47;TDF&#44; EFV&#47;FTC&#47;TDF&#44; or ATV&#47;r<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>FTC&#47;TDF to EVG&#47;c&#47;FTC&#47;TAF is virologically safe in patients whose virus remains sensitive to all the components in the regimen&#46; This change is also associated with improved bone mineral density and kidney function&#46; The switch is even feasible in patients with mild or moderate kidney failure &#40;A-I&#41;&#46;</p></li></ul></p><p id="par0530" class="elsevierStylePara elsevierViewall">&#40;g&#41; Switching to DTG&#47;ABC&#47;3TC from regimens containing 2 NRTI and PI&#44; NNRTI&#44; or INSTI</p><p id="par0535" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">&#8226;</span><p id="par0540" class="elsevierStylePara elsevierViewall">Switching to DTG&#47;ABC&#47;3TC&#44; from regimens containing 2 NRTI and PI&#44; NNRTI&#44; or INSTI is virologically safe&#46; This switch is an option in patients who wish to simplify their current regimen&#46;</p></li></ul></p><p id="par0545" class="elsevierStylePara elsevierViewall">&#40;h&#41; Switch from a boosted PI to MVC</p><p id="par0550" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">&#8226;</span><p id="par0555" class="elsevierStylePara elsevierViewall">Switching to 2 NRTI and MVC from regimens that contain 2 NRTI and PI is virologically safe if genotyping of proviral DNA shows that the virus is R5-tropic &#40;<span class="elsevierStyleItalic"><span class="elsevierStyleBold">A-I</span></span>&#41;</p></li></ul></p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">3&#46; Dual therapy with 3TC and ATV&#47;r&#44; DRV&#47;r or LPV&#47;r</span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Switching from 2 NRTI plus ATV&#47;r&#44; DRV&#47;r&#44; or LPV&#47;r to 3TC plus ATV&#47;r&#44; DRV&#47;r&#44; or LPV&#47;r</span><p id="par0560" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">&#8226;</span><p id="par0565" class="elsevierStylePara elsevierViewall">Switching from 2 NRTI<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ATV&#47;r or DRV&#47;r or LPV&#47;r to dual therapy with 3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ATV&#47;r or 3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>DRV&#47;r or 3TC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LPV&#47;r is an option if the clinician wishes to avoid or prevent the adverse effects caused by NRTI&#46; This option requires the patient to fulfill the following criteria&#58; &#40;1&#41; No chronic hepatitis B&#59; &#40;2&#41; PVL &#60;50<span class="elsevierStyleHsp" style=""></span>copies&#47;mL for at least 6 months&#59; and &#40;3&#41; No mutations in the protease gene or previous virological failure to PI&#47;r or 3TC &#40;A-I&#41;&#46;</p></li></ul></p></span></span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">4&#46; Monotherapy with PI&#47;r</span><p id="par0570" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#8226;</span><p id="par0575" class="elsevierStylePara elsevierViewall">Monotherapy with DRV&#47;r once daily or LPV&#47;r twice daily is a valid option for treating or preventing adverse effects caused by NRTI if the patient fulfills the following criteria&#58; &#40;1&#41; No chronic hepatitis B&#59; &#40;2&#41; PVL &#60;50<span class="elsevierStyleHsp" style=""></span>copies&#47;mL for at least 6 months&#59; &#40;3&#41; No mutations in the protease gene and no previous virological failure with PI &#40;B-I&#41;&#46; Since there are no data on the efficacy of monotherapy with DRV&#47;c&#44; this regimen cannot be recommended at present&#46; Given that monotherapy with DRV&#47;r or LPV&#47;r carries a greater risk of viral rebound than dual therapy with DRV&#47;r or LPV&#47;r with 3TC&#44; this Committee recommends the use of monotherapy only in unusual cases where dual therapy cannot be used&#46;</p></li></ul></p></span></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Failure of ART</span><p id="par0580" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Definition</span> of <span class="elsevierStyleItalic">virological failure &#40;VF&#41;</span>&#46; Two confirmed determinations of PVL &#62;50<span class="elsevierStyleHsp" style=""></span>copies&#47;mL 24 weeks after initiating ART&#46;</p><p id="par0585" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0195"><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">&#8226;</span><p id="par0590" class="elsevierStylePara elsevierViewall">The objective of rescue ART is to achieve a PVL &#60;50<span class="elsevierStyleHsp" style=""></span>copies&#47;mL &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8226;</span><p id="par0595" class="elsevierStylePara elsevierViewall">Switching ART because of VF should be performed early to avoid accumulation of mutations and to facilitate the response to the new treatment &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#8226;</span><p id="par0600" class="elsevierStylePara elsevierViewall">The new ART regimen should contain 3 totally active antiretroviral drugs&#46; If this is not possible&#44; 2 fully active drugs should be combined with other drugs that maintain partial virological activity&#44; especially in the case of advanced rescue in patients with limited therapeutic options &#40;A-I&#41;&#46; Regimens with only 2 active antiretroviral drugs based on a boosted PI may be a reasonable option in patients who have experienced a non-advanced failure when it is not possible to use NRTI or construct a simple regimen with 3 active drugs &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">&#8226;</span><p id="par0605" class="elsevierStylePara elsevierViewall">Resistance and viral tropisms should be assessed in order to design the best alternative regimen&#46; The test should be performed while the patient is receiving the failed treatment or as soon as possible after suspension of the failed treatment&#46; If the results of previous genotyping tests are available&#44; all the resistance mutations detected should be evaluated &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">&#8226;</span><p id="par0610" class="elsevierStylePara elsevierViewall">The causes of VF&#8212;poor adherence&#44; drug or food interactions&#44; previous intolerance and previous toxicity&#8212;should be analyzed&#46; The new regimen should be comfortable and well tolerated &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">&#8226;</span><p id="par0615" class="elsevierStylePara elsevierViewall">In patients who have experienced VF&#44; DRV&#47;r is the PI&#47;r that has proven most efficacious in all the rescue lines&#46; When major resistance mutations are present&#44; the recommended dose is 600&#47;100<span class="elsevierStyleHsp" style=""></span>mg BID &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">&#8226;</span><p id="par0620" class="elsevierStylePara elsevierViewall">DTG is the INSTI of choice in patients who experience VF who are INSTI-na&#239;ve &#40;A-I&#41;&#46; In the case of previous failure to RAL or EVG&#44; the recommended dose of DTG is 50<span class="elsevierStyleHsp" style=""></span>mg BID&#44; accompanied by optimized background therapy &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">&#8226;</span><p id="par0625" class="elsevierStylePara elsevierViewall">The use of tipranavir&#47;ritonavir &#40;TPV&#47;r&#41;&#44; enfuvirtide&#44; or thymidine analogs is restricted to patients with no other therapeutic options &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">&#8226;</span><p id="par0630" class="elsevierStylePara elsevierViewall">In patients with low-grade VF &#40;PVL detectable but &#8804;200<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#41;&#44; genotyping can be performed with a 2&#8211;3&#8211;mL plasma sample &#40;A-II&#41;&#46; If genotyping does not reveal resistance mutations&#44; an ART regimen with a high barrier to resistance should be maintained&#46; In patients with a PVL &#62;200<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#44; genotyping should be performed&#46; The choice of the new ART regimen should be based on both resistance mutations and previous ART&#46; ART should not be intensified with a single drug &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">&#8226;</span><p id="par0635" class="elsevierStylePara elsevierViewall">ART should not be suspended in patients with advanced VF and no therapeutic options &#40;A-II&#41;&#46; In this situation&#44; the approach should involve antiretroviral drugs that reduce viral replicative capacity and do not lead to resistance mutations that might compromise future treatments &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">&#8226;</span><p id="par0640" class="elsevierStylePara elsevierViewall">In patients with no therapeutic options&#44; it is important to monitor the CD4&#43; count and PVL and to consult with clinicians and virologists specialized in resistance and rescue therapy who are involved in restricted access programs &#40;B-III&#41;&#46;</p></li></ul></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Factors affecting the success of ART</span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">1&#46; Adherence</span><p id="par0645" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">&#8226;</span><p id="par0650" class="elsevierStylePara elsevierViewall">Before initiating ART&#44; the patient should be prepared and factors likely to limit adherence should be identified and corrected &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">&#8226;</span><p id="par0655" class="elsevierStylePara elsevierViewall">Once ART has been initiated&#44; a first check-up should be made after 2&#8211;4 weeks to verify adherence and correct adherence problems if necessary &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">&#8226;</span><p id="par0660" class="elsevierStylePara elsevierViewall">Adherence should be monitored and reinforced at visits to the doctor &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">&#8226;</span><p id="par0665" class="elsevierStylePara elsevierViewall">Adherence should be monitored by a multidisciplinary team including a doctor&#44; nursing staff&#44; specialists in psychological support&#44; and a hospital pharmacist &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">&#8226;</span><p id="par0670" class="elsevierStylePara elsevierViewall">In the case of patients whose adherence is irregular&#44; it is recommended to use regimens based on boosted PI&#44; preferably DRV because of its high genetic barrier to resistance&#44; in order to prevent the development of resistance &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">&#8226;</span><p id="par0675" class="elsevierStylePara elsevierViewall">Using fixed dose combinations of antiretroviral drugs simplifies ART and thus facilitates continued adherence&#46; The use of whole regimens in a single tablet is the most efficient strategy for preventing selective poor adherence &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">2&#46; Tolerability and adverse effects</span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">&#40;a&#41; Immediate adverse effects</span><p id="par0680" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">&#8226;</span><p id="par0685" class="elsevierStylePara elsevierViewall">Avoid the use of antiretroviral drugs whose immediate adverse effects are similar to clinical manifestations or laboratory abnormalities that are already present in a specific patient &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">&#8226;</span><p id="par0690" class="elsevierStylePara elsevierViewall">HLA-B&#42;5701 testing is mandatory before prescribing ABC&#44; since it has a negative predictive value of almost 100&#37; for the risk of hypersensitivity reaction to this drug &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">&#8226;</span><p id="par0695" class="elsevierStylePara elsevierViewall">If the adverse effect is very intense or long-lasting or cannot be tolerated by the patient&#44; the potential culprit antiretroviral drug&#40;s&#41; should be switched &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">&#40;b&#41; Late adverse effects</span><p id="par0700" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">&#8226;</span><p id="par0705" class="elsevierStylePara elsevierViewall">ART should be tailored by evaluating the risk or presence of chronic diseases in such a way that the regimen selected does not contain antiretroviral drugs that can favor the onset or progression of these diseases &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">&#8226;</span><p id="par0710" class="elsevierStylePara elsevierViewall">Withdrawal of some of the antiretroviral drugs involved in late adverse effects can improve&#8212;albeit partially&#8212;the underlying clinical abnormality&#44; although it is not known whether such a modification can alter the natural history of the specific chronic disease or survival&#46; Antiretroviral drugs contribute collaterally to the risk or progression of specific chronic diseases&#44; although other factors are generally considered to be more important&#46; Priority should be given to interventions to address these factors &#40;A-II&#41;&#46;</p></li></ul></p></span></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">3&#46; Drug interactions</span><p id="par0715" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">&#8226;</span><p id="par0720" class="elsevierStylePara elsevierViewall">All medications&#44; natural products&#44; alternative medicines and recreational drugs taken by the patient should be recorded in the clinical history in order to evaluate potential interactions &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">&#8226;</span><p id="par0725" class="elsevierStylePara elsevierViewall">Contraindications should be taken into account and the corresponding dose adjustments made where necessary &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">&#8226;</span><p id="par0730" class="elsevierStylePara elsevierViewall">Plasma levels should be monitored when prescribing two or more drugs with potential pharmacokinetic interactions in order to avoid toxicity or lack of efficacy &#40;A-II&#41;&#46;</p></li></ul></p></span></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Special situations</span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">1&#46; Acute HIV infection</span><p id="par0735" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">&#8226;</span><p id="par0740" class="elsevierStylePara elsevierViewall">ART should be recommended in all patients with acute HIV infection&#44; regardless of the symptoms&#44; their severity&#44; or their duration &#40;A-II&#41; and should be started as soon as possible to obtain the maximum benefit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">&#8226;</span><p id="par0745" class="elsevierStylePara elsevierViewall">If ART is to be initiated&#44; it should be done so with the same preferential regimens used to treat chronic HIV infection &#40;A-I&#41; &#40;Table 1&#41;&#46; A regimen comprising 2 NRTI &#40;preferably TAF-TDF&#47;FTC&#41; and an INSTI could reduce PVL more rapidly during the first 4&#8211;8 weeks than PI or NNRTI and&#44; thus&#44; make it easier to reduce transmission of HIV &#40;A-I&#41; and reach higher concentrations in genital tract secretions &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">&#8226;</span><p id="par0750" class="elsevierStylePara elsevierViewall">If the results of resistance testing are not available&#44; it is preferable to begin with a regimen based on DTG or boosted DRV until the results become available &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">&#8226;</span><p id="par0755" class="elsevierStylePara elsevierViewall">If is ART is initiated&#44; it should be administered indefinitely &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">2&#46; Infection by HIV-2</span><p id="par0760" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0225"><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">&#8226;</span><p id="par0765" class="elsevierStylePara elsevierViewall">The general principles of ART in patients infected by HIV-2 should be the same as those of HIV-1 infection &#40;A-III&#41;&#46; Clinical monitoring is recommended&#46; The CD4&#43; lymphocyte count should be determined every 3&#8211;6 month&#44; as should HIV-2 PVL&#44; if available&#46;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">&#8226;</span><p id="par0770" class="elsevierStylePara elsevierViewall">The preferred regimen for initial ART in these patients is the combination of 2 NRTI and 1 INSTI or a boosted PI &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">&#8226;</span><p id="par0775" class="elsevierStylePara elsevierViewall">The use of NNRTI&#44; MVC&#44; or ENF is not indicated for the treatment of HIV-2 infection &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">3&#46; Pregnancy</span><p id="par0780" class="elsevierStylePara elsevierViewall">A specific GESIDA document is available&#46; The most important recommendations are summarized below&#46;</p><p id="par0785" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0230"><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">&#8226;</span><p id="par0790" class="elsevierStylePara elsevierViewall">All pregnant women must undergo HIV serology testing &#40;A-I&#41;&#46; If the result is negative&#44; testing must be repeated during the third trimester &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">&#8226;</span><p id="par0795" class="elsevierStylePara elsevierViewall">Pre-pregnancy counseling must form part of health care for HIV-infected women of childbearing age and should include a recommendation for ART so that the woman can become pregnant with an undetectable PVL &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">&#8226;</span><p id="par0800" class="elsevierStylePara elsevierViewall">ART is indicated in all pregnant women&#44; irrespective of CD4&#43; T-lymphocyte count and PVL&#44; in order to ensure that PVL remains undetectable for as long as possible during pregnancy&#44; especially during the third trimester and at delivery &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">&#8226;</span><p id="par0805" class="elsevierStylePara elsevierViewall">The choice of specific antiretroviral drugs should be based on resistance studies&#44; drug safety&#44; and ease of adherence&#46; If there are no resistance mutations&#44; the regimen of choice is TDF or ABC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3TC or FTC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LPV&#47;r or ATV&#47;r &#40;A-I&#41; or DRV&#47;r &#40;A-II&#41; or RAL &#40;A-II&#41;&#59; if resistance mutations are detected&#44; patients can receive any of the &#8220;preferential&#8221; and &#8220;alternative&#8221; antiretroviral drugs after a personalized evaluation &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">&#8226;</span><p id="par0810" class="elsevierStylePara elsevierViewall">Intrapartum intravenous administration of ZDV is only indicated in women whose PVL is &#62;1000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL or unknown at the time of delivery&#44; irrespective of any previous ART received &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0505"><span class="elsevierStyleLabel">&#8226;</span><p id="par0815" class="elsevierStylePara elsevierViewall">Elective cesarean delivery is indicated at week 38 in women with a pre-labor PVL of &#62;1000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">&#8226;</span><p id="par0820" class="elsevierStylePara elsevierViewall">Mothers cannot breastfeed&#46; Adapted formula food must be used &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">4&#46; Comorbid conditions</span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">&#40;a&#41; Initial ART in patients with opportunistic infections other than tuberculosis</span><p id="par0825" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0235"><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">&#8226;</span><p id="par0830" class="elsevierStylePara elsevierViewall">In most opportunistic infections &#40;except tuberculosis and cryptococcal meningitis&#41;&#44; ART should be started as soon as possible &#40;preferably within the first 15 days after starting treatment for the infection&#41; &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">&#8226;</span><p id="par0835" class="elsevierStylePara elsevierViewall">Patients with Pneumocystis jiroveci pneumonia who are not receiving ART&#44; should start ART during the 2 weeks following the diagnosis of Pneumocystis jiroveci pneumonia &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">&#8226;</span><p id="par0840" class="elsevierStylePara elsevierViewall">In patients with cryptococcal meningitis&#44; initiation of ART should be deferred for 5 weeks because of the greater risk of death associated with early initiation &#40;especially in patients with &#60;5<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L in CSF or increased intracranial pressure&#41; &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">&#40;b&#41; ART and tuberculosis</span><p id="par0845" class="elsevierStylePara elsevierViewall">Treatment of tuberculosis in HIV-infected adults was the subject of a consensus document from GESIDA&#47;National AIDS Plan&#44; which is available for consultation&#46;</p></span></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">Optimal timing of ART</span><p id="par0850" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span></p><p id="par0855" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0240"><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">&#8226;</span><p id="par0860" class="elsevierStylePara elsevierViewall">ART should always be started during treatment of tuberculosis&#44; irrespective of the CD4&#43; T-lymphocyte count&#44; since it reduces the risk of death &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">&#8226;</span><p id="par0865" class="elsevierStylePara elsevierViewall">The optimal time for initiating ART depends on the CD4&#43; T-lymphocyte count&#46; If the CD4&#43; T-lymphocyte count is &#60;50<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; ART should be started as soon as possible&#44; after verifying tolerance to anti-tuberculosis treatment&#44; but not later than the first 2 weeks &#40;A-I&#41;&#46; If the CD4&#43; T-lymphocyte count is &#62;50<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; initiation of ART can be delayed until the intense phase of anti-tuberculosis treatment has been completed &#40;8 weeks&#41;&#46; This approach reduces the risk of adverse effects and the development of immune reconstitution inflammatory syndrome &#40;IRIS&#41; without compromising survival &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">ART regimens</span><p id="par0870" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0245"><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">&#8226;</span><p id="par0875" class="elsevierStylePara elsevierViewall">Choice of NRTI&#58; No significant interactions or evidence of toxicity have been found between antituberculosis drugs and NRTI&#46; Therefore&#44; ABC&#44; TDF&#44; 3TC&#44; and FTC can be used in these patients with no added risks &#40;A-I&#41;&#46; However&#44; a relevant interaction could occur between TAF and the rifamycins&#44; with a decrease in absorption and in the plasma concentration of TAF&#44; since TAF is transported by glycoprotein P &#40;P-gp&#41; and the rifamycins induce the activity of this protein&#46;</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">&#8226;</span><p id="par0880" class="elsevierStylePara elsevierViewall">Choice of the third drug&#46; Since most experience and the best results have been obtained with EFV&#44; this is the antiretroviral drug of choice &#40;A-I&#41;&#46; The dose of EFV is standard for all patients &#40;600<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#44; irrespective of body weight and with no need to increase to 800<span class="elsevierStyleHsp" style=""></span>mg&#47;d &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">&#8226;</span><p id="par0885" class="elsevierStylePara elsevierViewall">Alternative third drugs&#46; Based on experience or sufficient evidence&#44; the alternative regimens that can be recommended include NVP at habitual doses &#40;A-II&#41; and RAL at 800<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h &#40;A-II&#41;&#44; although 400<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h has proven to be efficacious&#44; as has MVC at 600<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h &#40;A-III&#41;&#46; Despite the absence of clinical data&#44; the results of pharmacokinetic studies show that DTG can be administered at 50<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>hours &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">&#8226;</span><p id="par0890" class="elsevierStylePara elsevierViewall">Drugs that cannot be used&#46; The other NNRTI &#40;RPV and ETV&#41;&#44; PI &#40;whether boosted or not with ritonavir or cobicistat&#41;&#44; and EVG should not be co-administered with rifampicin&#46; In the exceptional case of a PI being the only option for ART&#44; rifampicin should be replaced by rifabutin and the corresponding adjustment in drug doses should be made &#40;A-II&#41;&#46;</p></li></ul></p></span><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0310">Immune reconstitution inflammatory syndrome &#40;IRIS&#41;</span><p id="par0895" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0250"><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">&#8226;</span><p id="par0900" class="elsevierStylePara elsevierViewall">If the patient develops IRIS&#44; neither ART nor anti-tuberculosis medication should be interrupted &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">&#8226;</span><p id="par0905" class="elsevierStylePara elsevierViewall">The symptoms of IRIS can by managed by adding non-steroidal anti-inflammatory drugs in mild to moderate cases &#40;A-III&#41; or corticosteroids in moderate to severe forms &#40;A-II&#41;&#46;</p></li></ul></p><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0315">&#40;c&#41; Renal insufficiency</span><p id="par0910" class="elsevierStylePara elsevierViewall">For a complete overview of renal disorders in HIV-infected patients&#44; please consult the consensus document drafted by GESIDA&#44; the SEN&#44; and the SEQC&#46;</p><p id="par0915" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0255"><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">&#8226;</span><p id="par0920" class="elsevierStylePara elsevierViewall">It is necessary to adjust the dose of NRTI&#44; except for ABC &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">&#8226;</span><p id="par0925" class="elsevierStylePara elsevierViewall">No dose adjustment is required for NNRTI&#44; PI&#44; ENF&#44; RAL&#44; or DTG &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">&#8226;</span><p id="par0930" class="elsevierStylePara elsevierViewall">The dose of MVC should be adjusted if it is used in combination with potent CYP3A4 inhibitors such as PI &#40;except TPV&#47;r&#41;&#44; ketoconazole&#44; itraconazole&#44; clarithromycin&#44; and telithromycin &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">&#8226;</span><p id="par0935" class="elsevierStylePara elsevierViewall">Co-formulations of antiretroviral drugs are not advised in patients with significant renal insufficiency&#46; The co-formulation EVG&#47;c&#47;FTC&#47;TDF should not be used in patients with an eGFR &#60;70<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; The co-formulations EFV&#47;FTC&#47;TDF&#44; RPV&#47;EFV&#47;TDF&#44; and DTG&#47;ABC&#47;3TC should not be used in patients with eGFR &#60;50<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; The co-formulation EVG&#47;c&#47;FTC&#47;TAF should not be used in patients with eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; In these cases&#44; antiretroviral drugs should be administered separately and the appropriate adjustments made &#40;B-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">&#8226;</span><p id="par0940" class="elsevierStylePara elsevierViewall">In patients with renal insufficiency &#40;any stage&#41;&#44; kidney function should be closely monitored and nephrotoxic drugs avoided &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">&#8226;</span><p id="par0945" class="elsevierStylePara elsevierViewall">In patients with advanced chronic renal insufficiency&#44; the dose should be adjusted according to the recommendations of the summary of product characteristics&#44; taking into account possible drug interactions&#44; which are more common and more dangerous in this situation &#40;A-II&#41;&#46; In the absence of contraindications&#44; the combination of ABC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3TC &#40;adjusted for eGFR&#41; with an NNRTI or a non-boosted INSTI &#40;DTG or RAL&#41; or DRV&#47;r can be used &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">&#40;d&#41; Liver disease &#40;HCV&#44; HBV&#44; cirrhosis&#41;</span><p id="par0950" class="elsevierStylePara elsevierViewall">Both SEIMC and AEEH recently drafted guidelines for the management of hepatitis C&#46; Please consult the guidelines for more detailed information&#46;</p></span></span><span id="sec0305" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0325">Initiation of ART</span><p id="par0955" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0260"><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">&#8226;</span><p id="par0960" class="elsevierStylePara elsevierViewall">Patients co-infected with HCV should initiate ART irrespective of their CD4&#43; T lymphocyte count &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">&#8226;</span><p id="par0965" class="elsevierStylePara elsevierViewall">In patients who require treatment for hepatitis C&#44; it is generally preferable to initiate ART before starting treatment for HCV infection A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">&#8226;</span><p id="par0970" class="elsevierStylePara elsevierViewall">Patients co-infected with HBV for whom treatment of HBV infection is indicated should initiate ART containing TDF or TAF and FTC or 3TC &#40;A-I&#41;&#46;</p></li></ul></p></span><span id="sec0310" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0330">Choice of antiretroviral drugs</span><p id="par0975" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0265"><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">&#8226;</span><p id="par0980" class="elsevierStylePara elsevierViewall">Any antiretroviral drug can be used in patients with chronic liver disease and normal liver function&#44; including patients with cirrhosis &#40;Child-Pugh&#44; class A&#41; &#40;A-I&#41;&#44; although it seems reasonable to avoid dideoxynucleoside drugs and nevirapine &#40;A-III&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">&#8226;</span><p id="par0985" class="elsevierStylePara elsevierViewall">In patients with mild or moderate hepatocellular insufficiency &#40;Child&#8211;Pugh stage A or B&#41;&#44; INSTI do not require dose adjustments and are the drugs of choice &#40;A-I&#41;&#46; Boosted PI have a greater therapeutic margin than NNRTI &#40;A-II&#41;&#46; In patients with Child&#8211;Pugh stage C disease&#44; RAL does not require dose adjustment and ATV&#47;r and FPV&#47;r &#40;with the dose of FPV&#47;r adjusted&#41; are safe &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0625"><span class="elsevierStyleLabel">&#8226;</span><p id="par0990" class="elsevierStylePara elsevierViewall">With the exception of sofosbuvir&#44; currently used DAA &#40;simeprevir&#44; daclatasvir&#44; ledipasvir&#44; paritaprevir&#44; ombitasvir&#44; dasabuvir&#44; elbasvir and grazoprevir&#41; present significant pharmacokinetic interactions with antiretroviral drugs that may require doses to be adjusted or coadministration to be contraindicated &#40;A-I&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">&#8226;</span><p id="par0995" class="elsevierStylePara elsevierViewall">An updated pharmacologic interaction software package should be used before prescribing a DAA-containing regimen in a patient on ART &#40;A-III&#41;&#46;</p></li></ul></p><span id="sec0315" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0335">&#40;e&#41; Cancer</span><p id="par1000" class="elsevierStylePara elsevierViewall">Please refer to the relevant GESIDA documents for complete information on cancer in HIV-infected patients&#46;</p><p id="par1005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendations</span><ul class="elsevierStyleList" id="lis0270"><li class="elsevierStyleListItem" id="lsti0635"><span class="elsevierStyleLabel">&#8226;</span><p id="par1010" class="elsevierStylePara elsevierViewall">ART is an essential component of the treatment of HIV-infected patients with Kaposi sarcoma or non-Hodgkin lymphoma &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0640"><span class="elsevierStyleLabel">&#8226;</span><p id="par1015" class="elsevierStylePara elsevierViewall">Patients with other types of cancer who are not receiving ART should initiate therapy as soon as possible &#40;A-II&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0645"><span class="elsevierStyleLabel">&#8226;</span><p id="par1020" class="elsevierStylePara elsevierViewall">Given its pharmacological characteristics&#44; excellent tolerance&#44; and minimal interactions&#44; RAL should be the antiretroviral drug of choice&#44; where possible&#44; in patients receiving chemotherapy &#40;A-III&#41;&#46; DTG can be considered an alternative in cases of resistance to RAL &#40;C-III&#41;&#46;</p></li></ul></p></span></span></span><span id="sec0320" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0340">Comparative cost of the different antiretroviral combinations</span><p id="par1025" class="elsevierStylePara elsevierViewall">Together with the present consensus document&#44; GESIDA has published a pharmaco-economic study in which the cost-effectiveness of the recommended preferred and alternative regimens is evaluated&#46; Please consult the relevant document&#46;</p><p id="par1030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recommendation</span><ul class="elsevierStyleList" id="lis0275"><li class="elsevierStyleListItem" id="lsti0650"><span class="elsevierStyleLabel">&#8226;</span><p id="par1035" class="elsevierStylePara elsevierViewall">Cost-effectiveness criteria should be taken into account when deciding on initial ART &#40;A-III&#41;&#46;</p></li></ul></p></span><span id="sec0325" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0345">Conflicts of interest</span><p id="par1040" class="elsevierStylePara elsevierViewall">This consensus document was drafted without grant aid or other funding&#44; whether collective or individual&#44; from any private institutions&#46; The conflicts of interest not associated with this document declared by the Members of the Editorial Board are set out below&#46;</p><p id="par1045" class="elsevierStylePara elsevierViewall">Antonio Antela has received payment for participating in consultancy meetings&#44; acting as a researcher in clinical trials&#44; and speaking at meetings or symposia from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare&#46;</p><p id="par1050" class="elsevierStylePara elsevierViewall">Jos&#233; R&#46; Arribas has acted as a consultant for AbbVie Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; Tobira&#44; and ViiV Healthcare&#46; He has received grant support for clinical research from Janssen&#44; Merck Sharp &#38; Dohme&#44; and Gilead Sciences&#44; and payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1055" class="elsevierStylePara elsevierViewall">Victor Asensi has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare and has received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has also received research grants from Janssen&#46;</p><p id="par1060" class="elsevierStylePara elsevierViewall">Juan Berenguer has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead&#44; Janssen&#44; Janssen Therapeutics&#44; Merck Sharp &#38; Dohme&#44; and ViiV Health care&#46; He has received clinical research grant support from Bristol-Myers Squibb&#44; Merck Sharp &#38; Dohme&#44; and ViiV Health care and payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Health care&#46;</p><p id="par1065" class="elsevierStylePara elsevierViewall">Jos&#233; R&#46; Blanco has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has received clinical research grant support from Bristol-Myers Squibb y Gilead Sciences&#44; and payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1070" class="elsevierStylePara elsevierViewall">Jos&#233; Luis Casado has acted as a consultant for AbbVie and ViiV Healthcare&#46; He has received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and has received clinical research grants from Janssen&#44; Gilead Sciences&#44; and ViiV Healthcare&#46;</p><p id="par1075" class="elsevierStylePara elsevierViewall">Bonaventura Clotet has acted as a consultant&#44; participated in clinical trials&#44; and given paid talks for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1080" class="elsevierStylePara elsevierViewall">Manuel Crespo has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and has received clinical research grants from Gilead Sciences and ViiV Healthcare&#46; He has received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and for developing training presentations from Bristol-Myers Squibb&#44; Gilead Sciences&#44; and ViiV Healthcare&#46;</p><p id="par1085" class="elsevierStylePara elsevierViewall">Pere Domingo has acted as a consultant for AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare&#46; He has received clinical research grant support from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare and payment for talks from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare&#46;</p><p id="par1090" class="elsevierStylePara elsevierViewall">Carlos Due&#241;as has acted as a consultant for Gilead Sciences and Janssen&#46; He has received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1095" class="elsevierStylePara elsevierViewall">Jos&#233; M&#46; Gatell has acted as a consultant for AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has received clinical research grant support from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1100" class="elsevierStylePara elsevierViewall">Juan Luis G&#243;mez Sirvent has acted as a consultant for AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb and Merck Sharp &#38; Dohme&#46; He has also participated in clinical trials and studies sponsored by AbbVie&#44; Boehringer Ingelheim&#44; Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare and has received payment for talks from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1105" class="elsevierStylePara elsevierViewall">Juan Gonz&#225;lez Garc&#237;a has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; Has received clinical research grant support and payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has also received financial support to attend scientific meetings from Bristol-Myers Squibb&#44; Gilead Sciences and Janssen&#46;</p><p id="par1110" class="elsevierStylePara elsevierViewall">Jos&#233; Antonio Iribarren has acted as a consultant for AbbVie and Janssen&#44; and has received clinical research grant support from AbbVie&#44; Bristol-Myers Squibb&#44; Gobierno Vasco&#44; FIPSE&#44; and FISS&#46; He has also received financial support to attend scientific meetings from AbbVie&#44; Gilead Sciences&#44; Janssen&#44; and ViiV&#44; and has participated in training activities&#44; talks&#44; and symposia sponsored by AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; Novartis&#44; Janssen&#44; Pfizer&#44; and ViiV&#46;</p><p id="par1115" class="elsevierStylePara elsevierViewall">Jos&#233; L&#243;pez Aldeguer has acted as a consultant for Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare&#46; He has received clinical research grant support from ViiV Healthcare and has received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1120" class="elsevierStylePara elsevierViewall">Juan C&#46; L&#243;pez Bernaldo de Quir&#243;s has acted as a consultant for Janssen and ViiV Healthcare and has received lecture fees from AbbVie&#44; Bristol-Myers Squibb&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1125" class="elsevierStylePara elsevierViewall">Luis F&#46; L&#243;pez Cort&#233;s has received unrestricted research funding&#44; consultancy fees&#44; and lecture fees from and have served on the advisory boards of Abbvie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen-Cilag&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1130" class="elsevierStylePara elsevierViewall">Juan E&#46; Losa has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and has received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1135" class="elsevierStylePara elsevierViewall">Fernando Lozano has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck-Sharp &#38; Dohme&#44; and ViiV Healthcare and has received payment for training sessions from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck-Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1140" class="elsevierStylePara elsevierViewall">Josep Mallolas has acted as a consultant for AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and has received research grants from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has also received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1145" class="elsevierStylePara elsevierViewall">Ana Mari&#241;o has received grant aid for attendance at conferences and meetings from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and ViiV Healthcare&#46;</p><p id="par1150" class="elsevierStylePara elsevierViewall">Esteban Mart&#237;nez has acted as a consultant for AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Merck Sharp &#38; Dohme&#44; Theratechnologies&#44; and ViiV Healthcare&#46; He has also received research grants from Merck Sharp &#38; Dohme and payment for training sessions from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; MerckSharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1155" class="elsevierStylePara elsevierViewall">Jos&#233; M&#46; Mir&#243; has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; Novartis&#44; and Sanofi and has received clinical research grant support from Cubist&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; Novartis&#44; Fondo de Investigaciones Sanitarias &#40;FIS&#41; del Instituto de Salud Carlos III &#40;Madrid&#41;&#44; Fundaci&#243;n para la Investigaci&#243;n y Prevenci&#243;n del Sida en Espa&#241;a &#40;FIPSE&#44; Madrid&#41;&#44; Ministerio de Sanidad&#44; Servicios Sociales e Igualdad &#40;MSSSI&#44; Madrid&#41;&#44; National Institutes of Health &#40;NIH&#44; Bethesda&#44; MA&#44; USA&#41;&#44; and NEAT&#46; He has also received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; Novartis&#44; and ViiV Healthcare&#46;</p><p id="par1160" class="elsevierStylePara elsevierViewall">Santiago Moreno has acted as a consultant for AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and Roche Pharma&#44; and has received clinical research grant support from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and Roche Pharma&#46; He has also received payment for talks from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and Roche Pharma&#46;</p><p id="par1165" class="elsevierStylePara elsevierViewall">Rosario Palacios has acted as a consultant for Bristol-Myers Squibb&#44; Gilead Sciences&#44; and Janssen and has received payment for talks from Bristol-Myers Squibb&#44; Merck Sharp &#38; Dohme&#44; Janssen&#44; Gilead Sciences&#44; and ViiV-Healthcare&#46;</p><p id="par1170" class="elsevierStylePara elsevierViewall">Juan Pasquau has received payment during the last 3 years for scientific consultancy services from AbbVie&#44; Bristol-Myers Squibb&#44; Janssen&#44; and ViiV Healthcare and for lectures and other training activities from Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has also received research grants from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1175" class="elsevierStylePara elsevierViewall">Jos&#233; A&#46; P&#233;rez Molina has acted as a consultant for Bristol-Myers Squibb&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and has received payment for talks from Bristol-Myers Squibb&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1180" class="elsevierStylePara elsevierViewall">Juan A&#46; Pineda declares that he has received payment for consultancy services from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Janssen&#44; and Merck Sharp &#38; Dohme&#44; and research grants from Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; Roche Pharma&#44; and ViiV Healthcare&#46; He has also received payment for talks from Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; Roche Pharma&#44; and ViiV Healthcare&#46;</p><p id="par1185" class="elsevierStylePara elsevierViewall">Daniel Podzamczer has received research grants and&#47;or consultancy fees and&#47;or lecture fees from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1190" class="elsevierStylePara elsevierViewall">Rosa Polo declares that she has not received any grant aid or subsidies associated with this document&#46;</p><p id="par1195" class="elsevierStylePara elsevierViewall">Joaqu&#237;n Portilla has acted as a consultant for AbbVie&#44; Gilead Sciences&#44; and Janssen&#59; he has received payment for talks from AbbVie&#44; Bristol Myers-Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1200" class="elsevierStylePara elsevierViewall">Eva Poveda has received grants for attending conferences and scientific meetings from Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; She has received payment for talks from Janssen Cilag and Merck Sharp &#38; Dohme and grants for developing research projects and biomedical training activities from Gilead Sciences and Janssen&#46;</p><p id="par1205" class="elsevierStylePara elsevierViewall">Federico Pulido has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and has received payment for talks from Abbott Laboratories&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1210" class="elsevierStylePara elsevierViewall">Antonio Rivero has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has received clinical research grant support from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1215" class="elsevierStylePara elsevierViewall">Rafael Rubio has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; and Janssen and has received payment for talks from AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; Roche Phasma&#44; and ViiV Healthcare&#46;</p><p id="par1220" class="elsevierStylePara elsevierViewall">Jes&#250;s Santos has acted as a consultant for Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and&#160;ViiV-Healthcare and has received fees for educational talks from Bristol-Myers Squibb&#44; Merck Sharp &#38; Dohme&#44; Janssen&#44; Gilead Sciences&#44; and ViiV-Healthcare&#46;</p><p id="par1225" class="elsevierStylePara elsevierViewall">Jos&#233; Sanz Moreno has participated in clinical trials sponsored by Bristol-Myers Squibb&#44; and ViiV Healthcare&#46; He has received payment for consultancy work and preparing training presentations for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1230" class="elsevierStylePara elsevierViewall">Jes&#250;s Sanz Sanz has acted as a consultant for AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46; He has received payment for talks from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#44; and for preparing training presentations from ViiV Healthcare&#46;</p><p id="par1235" class="elsevierStylePara elsevierViewall">Mar&#237;a Jes&#250;s T&#233;llez has acted as a consultant for AbbVie&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; and Janssen and has received payment for talks from Gilead Sciences and Janssen&#46;</p><p id="par1240" class="elsevierStylePara elsevierViewall">Javier de la Torre has acted as a consultant for Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare and has received payment for talks from AbbVie&#44; Boehringer Ingelheim&#44; Bristol-Myers Squibb&#44; Gilead Sciences&#44; GlaxoSmithKline&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p><p id="par1245" class="elsevierStylePara elsevierViewall">Montserrat Tuset has received clinical research grant support from Bristol-Myers Squibb&#44; Gilead Sciences&#44; Janssen&#44; and Merck Sharp &#38; Dohme and payment for talks from Gilead Sciences&#44; Janssen&#44; Merck Sharp &#38; Dohme&#44; and ViiV Healthcare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:15 [
        0 => array:3 [
          "identificador" => "xres1063872"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1011993"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1063871"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1011992"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Clinical and laboratory evaluation as a guide for ART"
          "secciones" => array:8 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Clinical evaluation"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Laboratory tests"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "CD4&#43; lymphocytes"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Plasma viral load"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Plasma concentration of antiretroviral drugs"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Resistance of HIV-1 to antiretroviral drugs"
            ]
            6 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Determination of the HLA-B&#42;5701 allele"
            ]
            7 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Determination of tropism"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Initial antiretroviral therapy"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "When should ART be initiated&#63;"
            ]
            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Which combination of antiretroviral drugs should be used&#63;"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "1&#46; NRTI"
            ]
            3 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "2&#46; NNRTI"
            ]
            4 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "3&#46; PI boosted with ritonavir or cobicistat &#40;PI&#47;r or PI&#47;c&#41;"
            ]
            5 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "4&#46; INSTI"
            ]
          ]
        ]
        7 => array:3 [
          "identificador" => "sec0090"
          "titulo" => "Switching ART in patients with an undetectable PVL"
          "secciones" => array:22 [
            0 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Remarks on the new regimen"
            ]
            1 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Virological considerations when switching efficacious ART"
            ]
            2 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "1&#46; Switching drugs from the same family"
            ]
            3 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Switching from ABC&#47;3TC to TDF&#47;FTC"
            ]
            4 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Switching from TDF to ABC"
            ]
            5 => array:2 [
              "identificador" => "sec0120"
              "titulo" => "Switching from TDF&#47;FTC to TAF&#47;FTC"
            ]
            6 => array:2 [
              "identificador" => "sec0125"
              "titulo" => "Switching from EFV&#47;TDF&#47;FTC to RPV&#47;TDF&#47;FTC"
            ]
            7 => array:2 [
              "identificador" => "sec0130"
              "titulo" => "Switching from RPV&#47;TDF&#47;FTC to RPV&#47;TAF&#47;FTC"
            ]
            8 => array:2 [
              "identificador" => "sec0135"
              "titulo" => "Switching from EFV or NVP &#43; 2 NRTI to EFV&#47;TDF&#47;FTC"
            ]
            9 => array:2 [
              "identificador" => "sec0140"
              "titulo" => "Switching from ATV&#47;r &#43; ABC&#47;3TC to unboosted ATV &#43; ABC&#47;3TC"
            ]
            10 => array:2 [
              "identificador" => "sec0145"
              "titulo" => "Switching from ATV&#47;r or DRV&#47;r to ATV&#47;c or DRV&#47;c"
            ]
            11 => array:2 [
              "identificador" => "sec0150"
              "titulo" => "Switching from ATV&#47;r &#43; TDF&#47;FTC to unboosted ATV &#43; ABC&#47;3TC"
            ]
            12 => array:2 [
              "identificador" => "sec0155"
              "titulo" => "2&#46; Switching to antiretroviral drugs from a different family"
            ]
            13 => array:2 [
              "identificador" => "sec0160"
              "titulo" => "Switching from TDF to RAL"
            ]
            14 => array:2 [
              "identificador" => "sec0165"
              "titulo" => "Switching from EFV to RAL"
            ]
            15 => array:2 [
              "identificador" => "sec0170"
              "titulo" => "Switching from TDF&#47;FTC &#43; EFV or NVP to EVG&#47;c&#47;FTC&#47;TDF"
            ]
            16 => array:2 [
              "identificador" => "sec0175"
              "titulo" => "Switching from a boosted PI to EFV&#47;FTC&#47;TDF"
            ]
            17 => array:2 [
              "identificador" => "sec0180"
              "titulo" => "Switching from boosted PI to RPV&#47;FTC&#47;TDF"
            ]
            18 => array:2 [
              "identificador" => "sec0185"
              "titulo" => "Switching from boosted PI to RAL"
            ]
            19 => array:2 [
              "identificador" => "sec0190"
              "titulo" => "Switching from boosted PI to EVG&#47;c&#47;FTC&#47;TDF"
            ]
            20 => array:3 [
              "identificador" => "sec0195"
              "titulo" => "3&#46; Dual therapy with 3TC and ATV&#47;r&#44; DRV&#47;r or LPV&#47;r"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0200"
                  "titulo" => "Switching from 2 NRTI plus ATV&#47;r&#44; DRV&#47;r&#44; or LPV&#47;r to 3TC plus ATV&#47;r&#44; DRV&#47;r&#44; or LPV&#47;r"
                ]
              ]
            ]
            21 => array:2 [
              "identificador" => "sec0205"
              "titulo" => "4&#46; Monotherapy with PI&#47;r"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0210"
          "titulo" => "Failure of ART"
        ]
        9 => array:3 [
          "identificador" => "sec0215"
          "titulo" => "Factors affecting the success of ART"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0220"
              "titulo" => "1&#46; Adherence"
            ]
            1 => array:3 [
              "identificador" => "sec0225"
              "titulo" => "2&#46; Tolerability and adverse effects"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0230"
                  "titulo" => "&#40;a&#41; Immediate adverse effects"
                ]
                1 => array:2 [
                  "identificador" => "sec0235"
                  "titulo" => "&#40;b&#41; Late adverse effects"
                ]
              ]
            ]
            2 => array:2 [
              "identificador" => "sec0240"
              "titulo" => "3&#46; Drug interactions"
            ]
          ]
        ]
        10 => array:3 [
          "identificador" => "sec0245"
          "titulo" => "Special situations"
          "secciones" => array:9 [
            0 => array:2 [
              "identificador" => "sec0250"
              "titulo" => "1&#46; Acute HIV infection"
            ]
            1 => array:2 [
              "identificador" => "sec0255"
              "titulo" => "2&#46; Infection by HIV-2"
            ]
            2 => array:2 [
              "identificador" => "sec0260"
              "titulo" => "3&#46; Pregnancy"
            ]
            3 => array:3 [
              "identificador" => "sec0265"
              "titulo" => "4&#46; Comorbid conditions"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0270"
                  "titulo" => "&#40;a&#41; Initial ART in patients with opportunistic infections other than tuberculosis"
                ]
                1 => array:2 [
                  "identificador" => "sec0275"
                  "titulo" => "&#40;b&#41; ART and tuberculosis"
                ]
              ]
            ]
            4 => array:2 [
              "identificador" => "sec0280"
              "titulo" => "Optimal timing of ART"
            ]
            5 => array:2 [
              "identificador" => "sec0285"
              "titulo" => "ART regimens"
            ]
            6 => array:3 [
              "identificador" => "sec0290"
              "titulo" => "Immune reconstitution inflammatory syndrome &#40;IRIS&#41;"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0295"
                  "titulo" => "&#40;c&#41; Renal insufficiency"
                ]
                1 => array:2 [
                  "identificador" => "sec0300"
                  "titulo" => "&#40;d&#41; Liver disease &#40;HCV&#44; HBV&#44; cirrhosis&#41;"
                ]
              ]
            ]
            7 => array:2 [
              "identificador" => "sec0305"
              "titulo" => "Initiation of ART"
            ]
            8 => array:3 [
              "identificador" => "sec0310"
              "titulo" => "Choice of antiretroviral drugs"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0315"
                  "titulo" => "&#40;e&#41; Cancer"
                ]
              ]
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0320"
          "titulo" => "Comparative cost of the different antiretroviral combinations"
        ]
        12 => array:2 [
          "identificador" => "sec0325"
          "titulo" => "Conflicts of interest"
        ]
        13 => array:2 [
          "identificador" => "xack360045"
          "titulo" => "Acknowledgments"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1011993"
          "palabras" => array:7 [
            0 => "Antiretroviral therapy"
            1 => "HIV infection"
            2 => "AIDS"
            3 => "Consensus document"
            4 => "Recommendations"
            5 => "GESIDA"
            6 => "Spanish National AIDS Plan"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1011992"
          "palabras" => array:7 [
            0 => "Tratamiento antirretroviral"
            1 => "Infecci&#243;n por VIH"
            2 => "Sida"
            3 => "Documento de consenso"
            4 => "Recomendaciones"
            5 => "GESIDA"
            6 => "Plan Nacional sobre el Sida"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Antiretroviral therapy &#40;ART&#41; is recommended for all patients infected by HIV-1&#46; The objective of ART is to achieve an undetectable plasma viral load &#40;PVL&#41;&#46; Initial ART should be based on a combination of 3 drugs&#44; including 2 nucleoside reverse transcriptase inhibitors &#40;tenofovir in either of its two formulations plus emtricitabine or abacavir plus lamivudine&#41; and another drug from a different family&#46; Four of the recommended regimens&#44; all of which have an integrase inhibitor as the third drug &#40;dolutegravir&#44; elvitegravir boosted with cobicistat or raltegravir&#41;&#44; are considered preferential&#44; whereas a further 3 regimens &#40;based on elvitegravir&#47;cobicistat&#44; rilpivirine&#44; or darunavir boosted with cobicistat or ritonavir&#41; are considered alternatives&#46; We present the reasons and criteria for switching ART in patients with an undetectable PVL and in those who present virological failure&#44; in which case salvage ART should include 3 &#40;or at least 2&#41; drugs that are fully active against HIV&#46; We also update the criteria for ART in specific situations &#40;acute infection&#44; HIV-2 infection&#44; pregnancy&#41; and comorbidities &#40;tuberculosis or other opportunistic infections&#44; kidney disease&#44; liver disease and cancer&#41;&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se recomienda tratamiento antirretroviral &#40;TAR&#41; a todas las personas con infecci&#243;n por VIH-1&#46; El objetivo del TAR es lograr una carga viral plasm&#225;tica &#40;CVP&#41; indetectable&#46; El TAR inicial debe ser una combinaci&#243;n de 3 f&#225;rmacos&#44; que incluya 2 inhibidores de la transcriptasa inversa an&#225;logos de nucle&#243;sidos &#40;tenofovir en cualquiera de sus dos formas m&#225;s emtricitabina o abacavir m&#225;s lamivudina&#41; y otro de distinta familia&#46; Cuatro de las pautas recomendadas&#44; todas las cuales tienen un inhibidor de la integrasa como tercer f&#225;rmaco &#40;dolutegravir&#44; elvitegravir potenciado con cobicistat o raltegravir&#41;&#44; se consideran preferentes&#44; mientras que otras tres&#44; &#40;basadas en elvitegravir&#47;cobicistat&#44; rilpivirina o darunavir potenciado con cobicistat o ritonavir&#41;&#44; como alternativas&#46; Se exponen las causas y criterios para cambiar el TAR en los pacientes con carga viral plasm&#225;tica indetectable as&#237; como en los que presentan fracaso virol&#243;gico&#44; en cuyo caso el TAR de rescate debe incluir 3 &#40;o al menos 2&#41; f&#225;rmacos plenamente activos frente al VIH&#46; Se actualizan los criterios espec&#237;ficos del TAR en situaciones especiales &#40;infecci&#243;n aguda&#44; infecci&#243;n por VIH-2&#44; embarazo&#41; o comorbilidades &#40;tuberculosis u otras enfermedades oportunistas&#44; enfermedad renal&#44; hepatopat&#237;as y neoplasias&#41;&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0040">See writing committee in <a class="elsevierStyleCrossRef" href="#sec0330">Appendix A</a>&#46;</p>"
        "identificador" => "fn0005"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:3 [
            "etiqueta" => "Appendix A"
            "identificador" => "sec0330"
            "apendiceSeccion" => array:1 [
              0 => array:3 [
                "apendice" => "<p id="par1255" class="elsevierStylePara elsevierViewall">Antonio Rivero<span class="elsevierStyleSup">1</span>&#44; Rosa Polo<span class="elsevierStyleSup">2</span>&#44; Jos&#233; L&#243;pez Aldeguer<span class="elsevierStyleSup">3</span>&#44; Fernando Lozano<span class="elsevierStyleSup">4</span>&#44; Antonio Antela<span class="elsevierStyleSup">5</span>&#44; Jos&#233; Ram&#243;n Arribas<span class="elsevierStyleSup">6</span>&#44; V&#237;ctor Asensi<span class="elsevierStyleSup">7</span>&#44; Juan Berenguer<span class="elsevierStyleSup">8</span>&#44; Jos&#233; Ram&#243;n Blanco<span class="elsevierStyleSup">9</span>&#44; Jos&#233; Luis Casado<span class="elsevierStyleSup">10</span>&#44; Bonaventura Clotet<span class="elsevierStyleSup">11</span>&#44; Manuel Crespo<span class="elsevierStyleSup">12</span>&#44; Pere Domingo<span class="elsevierStyleSup">13</span>&#44; Carlos Due&#241;as<span class="elsevierStyleSup">14</span>&#44; Jos&#233; Mar&#237;a Gatell<span class="elsevierStyleSup">15</span>&#44; Juan Luis G&#243;mez-Sirvent<span class="elsevierStyleSup">16</span>&#44; Juan Gonz&#225;lez-Garc&#237;a<span class="elsevierStyleSup">17</span>&#44; Jos&#233; Antonio Iribarren<span class="elsevierStyleSup">18</span>&#44; Juan Carlos L&#243;pez Bernaldo de Quir&#243;s<span class="elsevierStyleSup">19</span>&#44; Luis Fernando L&#243;pez Cort&#233;s<span class="elsevierStyleSup">20</span>&#44; Juan Emilio Losa<span class="elsevierStyleSup">21</span>&#44; Josep Mallolas<span class="elsevierStyleSup">22</span>&#44; Ana Mari&#241;o<span class="elsevierStyleSup">23</span>&#44; Esteban Mart&#237;nez<span class="elsevierStyleSup">24</span>&#44; Jos&#233; M&#46; Mir&#243;<span class="elsevierStyleSup">25</span>&#44; Santiago Moreno<span class="elsevierStyleSup">26</span>&#44; Rosario Palacios<span class="elsevierStyleSup">27</span>&#44; Juan Pasquau<span class="elsevierStyleSup">28</span>&#44; Juan Antonio Pineda<span class="elsevierStyleSup">29</span>&#44; Daniel Podzamczer<span class="elsevierStyleSup">30</span>&#44; Joaqu&#237;n Portilla<span class="elsevierStyleSup">31</span>&#44; Eva Poveda<span class="elsevierStyleSup">32</span>&#44; Federico Pulido<span class="elsevierStyleSup">33</span>&#44; Rafael Rubio<span class="elsevierStyleSup">34</span>&#44; Jes&#250;s Santos<span class="elsevierStyleSup">35</span>&#44; Jos&#233; Sanz Moreno<span class="elsevierStyleSup">36</span>&#44; Jes&#250;s Sanz Sanz<span class="elsevierStyleSup">37</span>&#44; Mar&#237;a Jes&#250;s T&#233;llez<span class="elsevierStyleSup">38</span>&#44; Javier de la Torre<span class="elsevierStyleSup">39</span>&#44; Montserrat Tuset<span class="elsevierStyleSup">40</span>&#44; Jos&#233; A&#46; P&#233;rez Molina<span class="elsevierStyleSup">41</span>&#46;</p> <p id="par1260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">1</span>Hospital Universitario Reina Sof&#237;a&#47;IMIBIC&#44; C&#243;rdoba&#59; <span class="elsevierStyleSup">2</span>Secretar&#237;a del Plan Nacional sobre el Sida&#44; Ministerio de Sanidad&#44; Servicios Sociales e Igualdad&#59; <span class="elsevierStyleSup">3</span>Hospital Universitario La Fe&#44; IIS La Fe&#44; Valencia&#59; <span class="elsevierStyleSup">4</span>Hospital Universitario Virgen de Valme&#44; Sevilla&#59; <span class="elsevierStyleSup">5</span>Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#59; <span class="elsevierStyleSup">6</span>Hospital Universitario La Paz-IdiPAZ&#44; Madrid&#59; <span class="elsevierStyleSup">7</span>Hospital Universitario Central de Asturias&#44; Oviedo&#59; <span class="elsevierStyleSup">8</span>Hospital General Universitario Gregorio Mara&#241;&#243;n&#44; Madrid <span class="elsevierStyleSup">9</span>Hospital San Pedro-CIBIR&#44; Logro&#241;o&#59; <span class="elsevierStyleSup">10</span>Hospital Ram&#243;n y Cajal-IRYCIS&#44; Madrid&#59; <span class="elsevierStyleSup">11</span>Hospital Germans Trias i Pujol&#44; Badalona&#59; <span class="elsevierStyleSup">12</span>Complexo Hospitalario Universitario de Vigo&#59; <span class="elsevierStyleSup">13</span>Hospitals Universitaris Arnau de Vilanova i Santa Maria&#44; Universitat de Lleida&#44; IRB-Lleida&#44; Lleida&#59; <span class="elsevierStyleSup">14</span>Hospital Universitario de Valladolid &#40;HCUV&#41;&#59; <span class="elsevierStyleSup">15</span>Hospital Cl&#237;nic&#47;IDIBAPS&#44; UB&#44; Barcelona&#59; <span class="elsevierStyleSup">16</span>Hospital Universitario de Canarias&#44; Santa Cruz de Tenerife&#59; <span class="elsevierStyleSup">17</span>Hospital Universitario La Paz&#47;IdiPAZ&#44; Madrid&#59; <span class="elsevierStyleSup">18</span>Hospital Universitario Donostia&#44; San Sebasti&#225;n&#59; <span class="elsevierStyleSup">19</span>Hospital General Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#59; <span class="elsevierStyleSup">20</span>Hospital Universitario Virgen del Roc&#237;o&#44; Sevilla&#59; <span class="elsevierStyleSup">21</span>Hospital Universitario Fundaci&#243;n Alcorc&#243;n&#44; Alcorc&#243;n &#40;Madrid&#41;&#59; <span class="elsevierStyleSup">22</span>Hospital Cl&#237;nic&#47;IDIBAPS&#44; UB&#44; Barcelona&#59; <span class="elsevierStyleSup">23</span>Complejo Hospitalario Universitario de Ferrol&#59; <span class="elsevierStyleSup">24</span>Hospital Cl&#237;nic&#47;IDIBAPS&#44; UB&#44; Barcelona&#59; <span class="elsevierStyleSup">25</span>Hospital Cl&#237;nic&#47;IDIBAPS&#44; UB&#44; Barcelona&#59; <span class="elsevierStyleSup">26</span>Hospital Ram&#243;n y Cajal&#47;IRYCIS&#44; Madrid&#59; <span class="elsevierStyleSup">27</span>Hospital Universitario Virgen de la Victoria&#44; M&#225;laga&#59; <span class="elsevierStyleSup">28</span>Hospital Virgen de las Nieves&#44; Granada&#59; <span class="elsevierStyleSup">29</span>Hospital Universitario Virgen de Valme&#44; Sevilla&#59; <span class="elsevierStyleSup">30</span>IDIBELL-Hospital Universitario de Bellvitge&#44; L&#8217;Hospitalet&#44; Barcelona&#59; <span class="elsevierStyleSup">31</span>Hospital General Universitario&#44; Alicante&#59; <span class="elsevierStyleSup">32</span>Complejo Hospitalario Universitario&#44; A Coru&#241;a&#59; <span class="elsevierStyleSup">33</span>Hospital Universitario 12 de Octubre&#44; Madrid&#59; <span class="elsevierStyleSup">34</span>Hospital Universitario 12 de Octubre&#44; Madrid&#59; <span class="elsevierStyleSup">35</span>Hospital Universitario Virgen de la Victoria&#44; M&#225;laga&#59; <span class="elsevierStyleSup">36</span>Hospital Universitario Pr&#237;ncipe de Asturias&#44; Alcal&#225; de Henares&#44; Madrid&#59; <span class="elsevierStyleSup">37</span>Hospital Universitario de la Princesa&#44; Madrid&#59; <span class="elsevierStyleSup">38</span>Hospital Cl&#237;nico San Carlos&#44; Madrid&#59; <span class="elsevierStyleSup">39</span>Hospital Costa del Sol&#44; Marbella&#59; <span class="elsevierStyleSup">40</span>Hospital Cl&#237;nic&#47;IDIBAPS&#44; UB&#44; Barcelona&#59; <span class="elsevierStyleSup">41</span>Hospital Ram&#243;n y Cajal&#47;IRYCIS&#44; Madrid&#46;</p>"
                "titulo" => "Writing committee&#58;"
                "identificador" => "sec0335"
              ]
            ]
          ]
        ]
      ]
    ]
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ABC&#44; abacavir&#59; ATV&#47;r&#47;c&#44; atazanavir boosted with ritonavir or cobicistat&#59; c&#44; cobicistat&#59; DTG&#44; dolutegravir&#59; DRV&#47;r&#47;c&#44; darunavir boosted with ritonavir or cobicistat&#59; DRV&#47;r&#44; darunavir boosted with ritonavir&#59; eGFR&#44; estimated glomerular filtration rate&#59; EVG&#47;c&#44; elvitegravir boosted with cobicistat&#59; EFV&#44; efavirenz&#59; FTC&#44; emtricitabine&#59; INSTI&#44; integrase inhibitor&#59; NNRTI&#44; non-nucleoside reverse transcriptase inhibitors&#59; RAL&#44; raltegravir&#59; RPV&#44; rilpivirine&#59; TFV&#44; tenofovir in either of its 2 formulations&#59; TDF&#44; tenofovir-disoproxil fumarate&#59; TAF&#44; tenofovir-alafenamide&#59; 3TC&#44; lamivudine&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Third drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Regimen<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#8224;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Remarks<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#8225;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Preferred&#46;</span> Regimens that can be applied to most patients and whose efficacy in randomized clinical trials is superior to that of others or that&#44; while showing non-inferiority&#44; have additional advantages in terms of tolerance and toxicity or have a low risk of drug interactions&#46;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">INSTI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">ABC&#47;3TC&#47;DTG</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ABC is contraindicated in patients with a positive HLA-B5701 test result&#46; When ABC is prescribed&#44; the necessary measures should be taken to minimize all modifiable cardiovascular risk factors&#46;<br>- Few data for patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TFV</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#47;<span class="elsevierStyleBold">FTC</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">DTG</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Few data for patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TFV</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#47;<span class="elsevierStyleBold">FTC</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">RAL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TAF&#47;FTC&#47;EVG&#47;c</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Few data for patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L<br>- Greater potential for interactions than other INSTI-based regimens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Alternatives&#46;</span> Efficacious regimens that are not considered preferred because their efficacy was lower than that of preferred regimens in clinical trials or because they have potential drawbacks or restricted indications&#46; However&#44; they may be the regimen of choice in subgroups of patients or in special cases&#46;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">NNRTI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TFV</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#47;<span class="elsevierStyleBold">FTC&#47;RPV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Not indicated in patients with PVL &#62;100&#44;000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL<br>- Can be regimen of choice in patients with PVL &#60;100&#44;000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL &#40;more efficacious than TDF&#47;FTC&#47;EFV&#41;&#44; especially if simplicity is a priority<br>- Few data for patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L<br>- Perform genotyping before hand to rule out NNRTI resistance mutations&#46;<br>- Contraindicated in patients taking proton pump inhibitors&#46;<br>- Must always be taken with food&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Boosted PI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TFV</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#47;<span class="elsevierStyleBold">FTC</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">DRV&#47;r&#47;c</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Since sufficient data on this regimen are available for patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; it can be considered the regimen of choice in very immunodepressed patients&#44; especially when it is necessary to administer a regimen with a high genetic barrier &#40;patients with poor adherence&#41;&#46;<br>- Combination of PI&#47;r and TDF increases the risk of nephrotoxicity&#46;<br>- Greater likelihood of interactions than other regimens&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">INSTI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TDF&#47;FTC&#47;EVG&#47;c</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Few data for patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#46;<br>- Greater likelihood of interactions than other INSTI-based regimens&#46;<br>- Not indicated in patients with eGFR &#60;70<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; Use with caution in patients with eGFR &#60;90<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46;<br>- Can be considered a regimen of choice in women &#40;more efficacious than TDF&#47;FTC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ATV&#47;r&#41;&#44; especially if simplicity is a priority&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Other possible regimens&#46;</span> These regimens have also demonstrated efficacy&#59; however&#44; either available evidence is considered insufficient or the regimen has drawbacks with respect to regimens considered preferred or alternative</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">INSTI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">ABC&#47;3TC</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">RAL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ABC is contraindicated in patients with a positive HLA-B5701 test result&#46; When ABC is prescribed&#44; the necessary measures should be taken to minimize all modifiable cardiovascular risk factors&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">NNRTI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TDF&#47;FTC&#47;EFV o TAF&#47;FTC</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">EFV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Avoid in women planning to become pregnant and patients with neuropsychiatric disorders or suicidal ideation&#46; Use with caution in patients who perform dangerous tasks&#46;<br>- Since sufficient data are available on this regimen in patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; it can be used as the regimen of choice in very immunodepressed patients&#44; especially if simplicity is a priority &#40;if the combination is available as a coformulation&#41;&#46;<br>- Perform genotyping before hand to rule out NNRTI resistance mutations&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Boosted PI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">TFV</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&#47;<span class="elsevierStyleBold">FTC</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">ATV&#47;r&#47;c</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Avoid in patients taking proton pump inhibitors&#46;<br>- Since sufficient data on this regimen are available for patients with CD4&#43; &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; it can be considered the regimen of choice in very immunodepressed patients&#44; especially when it is necessary to administer a regimen with a high genetic barrier &#40;patients with poor adherence&#41;&#46;<br>- Combination of PI&#47;r and TDF increases the risk of nephrotoxicity&#46;<br>- Greater likelihood of interactions than other regimens&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">ABC&#47;3TC</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">DRV&#47;r&#47;c</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- ABC is contraindicated in patients with a positive HLA-B5701 test result&#46; When ABC is prescribed&#44; the necessary measures should be taken to minimize all modifiable cardiovascular risk factors&#46;<br>- Evaluate potential interactions&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">RAL</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">DRV&#47;r</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Do not use in patients with CD4 &#60;200<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#46;<br>- Avoid in patients with PVL &#62;100&#44;000<span class="elsevierStyleHsp" style=""></span>copies&#47;mL&#46;<br>- Can be used as an alternative to conventional triple therapy when neither TDF nor ABC can be prescribed&#46;<br>- Greater probability of interactions than other regimens&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1813916.png"
              ]
            ]
          ]
          "notaPie" => array:4 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "&#8224;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">When available&#44; fixed-dose combinations should be used&#46; There are no data showing that FTC and 3TC can be considered therapeutically equivalent&#59; therefore&#44; use of one or other drug in the regimens selected essentially depends on experience of use in combination with other drugs in the regimen&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">The clinical trials on which the evidence for each regimen is based are referenced in the text&#46;</p> <p class="elsevierStyleNotepara" id="npar0015">In drugs from the same family and with the same level of recommendation&#44; the order reflects the preference of the expert panel&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "&#8225;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The remarks reflect aspects that should be taken into consideration when choosing the regimen&#59; they do not aim to be an exhaustive guide to the precautions to be taken when receiving these drugs&#46; Please see the main text and the appropriate Summary of Product Characteristics for more information&#46;</p> <p class="elsevierStyleNotepara" id="npar0025">Cost and pricing of the therapeutic regimens are addressed elsewhere in these guidelines&#46; The cost-effectiveness of the regimens is analyzed formally in an article published simultaneously with the guidelines&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">TFV can be used as TDF or as TAF&#46; Both formulations have shown equivalent efficacy&#46; TDF should not be used if the eGFR is &#60;50<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46; TAF is preferred in patients with altered renal function or osteoporosis or who are at risk of these conditions&#46; The coformulations TAF&#47;FTC and TAF&#47;FTC&#47;RPV have been approved by the EMA&#44; although at the time of writing&#44; they are not sold in Spain&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "&#42;&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0035">DRV and ATV can be boosted with ritonavir or cobicistat&#46; Combination with cobicistat &#40;coformulation&#41; reduces the pill burden&#46; When choosing a booster&#44; it is important to review all possible interactions&#44; as these are not always identical with ritonavir and cobicistat&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recommended combinations of initial ART<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#8224;</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:2 [
            0 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Panel de Expertos de GESIDA y Plan Nacional sobre el Sida&#46; Documento de consenso de GESIDA&#47;Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana &#40;actualizaci&#243;n enero 2017&#41;&#46; Available from&#58; <a id="intr0005" class="elsevierStyleInterRef" href="http://www.gesida-seimc.org/guias_clinicas.php?mn_MP=406%26mn_MS=407">http&#58;&#47;&#47;www&#46;gesida-seimc&#46;org&#47;guias&#95;clinicas&#46;php&#63;mn&#95;MP&#61;406&#38;mn&#95;MS&#61;407</a> &#40;accessed 17&#46;02&#46;17&#41;&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Executive summary of the GESIDA&#47;National AIDS Plan Consensus Document on Antiretroviral Therapy in Adults Infected by the Human Immunodeficiency Virus &#40;Updated January 2016&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Study Group AIDS &#40;GESIDA&#41; of the Spanish Society of Infectious Diseases and Clinical Microbiology and the National AIDS Plan"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eimc.2016.02.028"
                      "Revista" => array:6 [
                        "tituloSerie" => "Enferm Infecc Microbiol Clin"
                        "fecha" => "2016"
                        "volumen" => "34"
                        "paginaInicial" => "439"
                        "paginaFinal" => "451"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27068257"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack360045"
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par1250" class="elsevierStylePara elsevierViewall">The Board of GESIDA and the National AIDS Plan acknowledge the contributions and opinions of Marisa &#193;lvarez&#44; Bel&#233;n Box&#44; Santiago Cenoz&#44; Inmaculada Clotet&#44; Manuel Cotarelo&#44; Adri&#225;n Curran&#44; Pedro Ferrer&#44; Beatriz Hern&#225;ndez-Novoa&#44; Marcela Gonz&#225;lez&#44; Cristina Gonz&#225;lez-Conde&#44; Carmen Gonz&#225;lez-Ortega&#44; Jos&#233; Emilio Mart&#237;n-Herrero&#44; Juli&#225;n Olalla&#44; Siria Pablos&#44; &#211;scar Rinc&#243;n&#44; Felipe Rodr&#237;guez-Alc&#225;ntara&#44; Nuria S&#225;nchez&#44; Ana Serra&#44; Sergio Serrano&#44; Jos&#233; Verdejo&#44; and Eugenia Vispo&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/0213005X/0000003600000007/v1_201807240423/S0213005X17301313/v1_201807240423/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "8681"
    "tipo" => "SECCION"
    "es" => array:2 [
      "titulo" => "Documento de consenso"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "es"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/0213005X/0000003600000007/v1_201807240423/S0213005X17301313/v1_201807240423/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17301313?idApp=UINPBA00004N"
]

Article information

ISSN: 0213005X
Original language: English

DOI:10.1016/j.eimc.2017.04.001

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 October	11	0	11
2024 September	14	3	17
2024 August	20	3	23
2024 July	14	3	17
2024 June	18	2	20
2024 May	17	4	21
2024 April	19	1	20
2024 March	29	8	37
2024 February	13	2	15
2024 January	18	1	19
2023 December	24	2	26
2023 November	17	2	19
2023 October	24	7	31
2023 September	23	2	25
2023 August	13	4	17
2023 July	14	6	20
2023 June	22	6	28
2023 May	20	4	24
2023 April	11	5	16
2023 March	14	4	18
2023 February	32	9	41
2023 January	17	4	21
2022 December	26	18	44
2022 November	42	9	51
2022 October	34	15	49
2022 September	28	13	41
2022 August	31	20	51
2022 July	35	9	44
2022 June	60	16	76
2022 May	36	20	56
2022 April	55	15	70
2022 March	35	17	52
2022 February	37	15	52
2022 January	21	18	39
2021 December	38	20	58
2021 November	26	18	44
2021 October	31	27	58
2021 September	24	16	40
2021 August	26	18	44
2021 July	36	21	57
2021 June	25	8	33
2021 May	30	12	42
2021 April	34	21	55
2021 March	21	2	23
2021 February	36	9	45
2021 January	21	11	32
2020 December	17	10	27
2020 November	20	10	30
2020 October	19	8	27
2020 September	53	10	63
2020 August	30	7	37
2020 July	28	10	38
2020 June	25	11	36
2020 May	28	10	38
2020 April	20	10	30
2020 March	22	9	31
2020 February	32	7	39
2020 January	32	12	44
2019 December	47	25	72
2019 November	13	9	22
2019 October	31	11	42
2019 September	27	14	41
2019 August	27	8	35
2019 July	22	26	48
2019 June	49	26	75
2019 May	114	40	154
2019 April	51	27	78
2019 March	20	17	37
2019 February	20	11	31
2019 January	8	2	10
2018 December	1	4	5
2018 November	4	2	6
2018 October	7	10	17
2018 September	16	18	34
2018 August	23	24	47
2018 July	33	95	128
2018 May	0	1	1
2018 March	0	1	1
2018 February	0	2	2
2018 January	0	3	3
2017 December	3	3	6
2017 November	0	9	9
2017 October	0	6	6
2017 September	0	2	2
2017 August	0	1	1
2017 June	0	7	7

Show all

Indexed in:

Follow us:

Subscribe:

Statistics

Indexed in:

Follow us:

Subscribe:

Statistics

Subscribe to our newsletter