Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the International Antiviral Society–USA Panel

Saag MS, Benson CA, Gandhi RT, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2018 recommendations of the International Antiviral Society-USA Panel. JAMA. 2018;320(4):379-396



Antiretroviral therapy (ART) is the cornerstone of prevention and management of HIV infection.


To evaluate new data and treatments and incorporate this information into updated recommendations for initiating therapy, monitoring individuals starting therapy, changing regimens, and preventing HIV infection for individuals at risk.

Evidence Review

New evidence collected since the International Antiviral Society–USA 2016 recommendations via monthly PubMed and EMBASE literature searches up to April 2018; data presented at peer-reviewed scientific conferences. A volunteer panel of experts in HIV research and patient care considered these data and updated previous recommendations.


ART is recommended for virtually all HIV-infected individuals, as soon as possible after HIV diagnosis. Immediate initiation (eg, rapid start), if clinically appropriate, requires adequate staffing, specialized services, and careful selection of medical therapy. An integrase strand transfer inhibitor (InSTI) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) is generally recommended for initial therapy, with unique patient circumstances (eg, concomitant diseases and conditions, potential for pregnancy, cost) guiding the treatment choice. CD4 cell count, HIV RNA level, genotype, and other laboratory tests for general health and co-infections are recommended at specified points before and during ART. If a regimen switch is indicated, treatment history, tolerability, adherence, and drug resistance history should first be assessed; 2 or 3 active drugs are recommended for a new regimen. HIV testing is recommended at least once for anyone who has ever been sexually active and more often for individuals at ongoing risk for infection. Preexposure prophylaxis with tenofovir disoproxil fumarate/emtricitabine and appropriate monitoring is recommended for individuals at risk for HIV.

Conclusions and Relevance

Advances in HIV prevention and treatment with antiretroviral drugs continue to improve clinical management and outcomes for individuals at risk for and living with HIV.


Michael S. Saag, MD
University of Alabama at Birmingham

Constance A. Benson, MD
University of California San Diego

Rajesh T. Gandhi, MD
Harvard Medical School

Jennifer F. Hoy, MBBS, FRACP
Monash University

Raphael J. Landovitz, MD
University of California Los Angeles

Michael J Mugavero, MD, MHSc
University of Alabama at Birmingham

Paul E. Sax, MD
Harvard Medical School

Davey M. Smith, MD
University of California San Diego

Melanie A. Thompson, MD
AIDS Research Consortium of Atlanta

Susan P. Buchbinder, MD
University of California San Francisco

Carlos del Rio, MD
Emory University School of Medicine

Joseph J. Eron, MD
The University of North Carolina at Chapel Hill

Gerd Fatkenheuer, MD
University of Cologne

Huldrych F. Günthard, MD
University Hospital Zurich

Jean-Michel Molina, MD
University of Paris Diderot

Donna M. Jacobsen, BS
International Antiviral Society-USA

Paul A. Volberding, MD
University of California San Francisco