Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2020 Recommendations of the International Antiviral Society–USA Panel

Saag MS, Gandhi RT, Hoy JF, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2020 recommendations of the International Antiviral Society-USA Panel. JAMA. 2020;324(16):1651-1669



Data on the use of antiretroviral drugs, including new drugs and formulations, for the treatment and prevention of HIV infection continue to guide optimal practices.


To evaluate new data and incorporate them into current recommendations for initiating HIV therapy, monitoring individuals starting on therapy, changing regimens, preventing HIV infection for those at risk, and special considerations for older people with HIV.

Evidence Review

New evidence was collected since the previous International Antiviral (formerly AIDS) Society–USA recommendations in 2018, including data published or presented at peer-reviewed scientific conferences through August 22, 2020. A volunteer panel of 15 experts in HIV research and patient care considered these data and updated previous recommendations.


From 5316 citations about antiretroviral drugs identified, 549 were included to form the evidence basis for these recommendations. Antiretroviral therapy is recommended as soon as possible for all individuals with HIV who have detectable viremia. Most patients can start with a 3-drug regimen or now a 2-drug regimen, which includes an integrase strand transfer inhibitor. Effective options are available for patients who may be pregnant, those who have specific clinical conditions, such as kidney, liver, or cardiovascular disease, those who have opportunistic diseases, or those who have health care access issues. Recommended for the first time, a long-acting antiretroviral regimen injected once every 4 weeks for treatment or every 8 weeks pending approval by regulatory bodies and availability. For individuals at risk for HIV, preexposure prophylaxis with an oral regimen is recommended or, pending approval by regulatory bodies and availability, with a long-acting injection given every 8 weeks. Monitoring before and during therapy for effectiveness and safety is recommended. Switching therapy for virological failure is relatively rare at this time, and the recommendations for switching therapies for convenience and for other reasons are included. With the survival benefits provided by therapy, recommendations are made for older individuals with HIV. The current coronavirus disease 2019 pandemic poses particular challenges for HIV research, care, and efforts to end the HIV epidemic.

Conclusions and Relevance

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


Michael S. Saag, MD
University of Alabama at Birmingham

Rajesh T. Gandhi, MD
Harvard Medical School

Jennifer F. Hoy, MBBS, FRACP
Monash University

Raphael J. Landovitz, MD
University of California Los Angeles

Melanie A. Thompson, MD
AIDS Research Consortium of Atlanta

Paul E. Sax, MD
Harvard Medical School

Davey M. Smith, MD
University of California San Diego

Constance A. Benson, MD
University of California San Diego

Susan P. Buchbinder, MD
University of California San Francisco

Carlos del Rio, MD
Emory University School of Medicine

Joseph J. Eron Jr, 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