GUIDELINES

1 GUIDELINESV ersion 2019 EnglishGUIDELINESV ersion 2021 EnglishEACS EuropeanAIDS Clinical Society1 EACS GUIDELINES of Contents Introduction to EACS GUIDELINES 20213 Summary of Changes from to Members5 Governing Board Members5 Abbreviations6 Part IAssessment of PLWH at Initial & Subsequent Visits7 Part IIART of PLWH10 Assessing PLWH's Readiness to Start and Maintain ART 10 Recommendations for Initiation of ART in PLWH with Chronic Infection without prior ART Exposure 12 Initial Combination Regimen for ART-na ve Adult PLWH 13 Primary HIV Infection (PHI)15 Switch Strategies for Virologically Suppressed Persons16 Virological Failure17 treatment of Pregnant Women Living with HIV or Women Considering Pregnancy18 ART in TB/HIV Co-infection20 Post-exposure Prophylaxis (PEP) 22 Pre-exposure Prophylaxis (PrEP)

2 23 Adverse Effects of ARVs and Drug Classes 24 Part IIIDrug-drug Interactions and Other Prescribing Issues in PLWH26 Drug-drug Interactions between ARVs and Non-ARVs27 Drug-drug Interactions between Analgesics and ARVs29 Drug-drug Interactions between Anticoagulants/Antiplatelet Agents and ARVs30 Drug-drug Interactions between Antidepressants and ARVs31 Drug-drug Interactions between Antihypertensives and ARVs32 Drug-drug Interactions between Anti-malarial Drugs and ARVs34 Drug-drug Interactions between Anti-tuberculosis Drugs and ARVs35 Drug-drug Interactions between Anxiolytics and ARVs36 Drug-drug Interactions between Bronchodilators (for COPD) and ARVs37 Drug-drug Interactions between Contraceptives and ARVs38 Drug-drug Interactions between Corticosteroids and ARVs40 Drug-drug Interactions between COVID-19 Therapies and ARVs41 Drug-drug Interactions between Hormone Replacement Therapy (HRT) and ARVs42 Drug-drug Interactions between Immunosuppressants (for SOT)

3 And ARVs43 Drug-drug Interactions between Pulmonary Antihypertensives and ARVs44 Drug-drug interactions between Viral Hepatitis Drugs and ARVs45 Administration of ARVs in PLWH with Swallowing Difficulties46 Dose Adjustment of ARVs for Impaired Hepatic Function49 Dose Adjustment of ARVs for Impaired Renal Function50 Selected Non-ARV Drugs Requiring Dosage Adjustment in Renal Insufficiency52 Prescribing in Older PLWH54 Selected Top 10 Drug Classes to Avoid in Older PLWH55 Dosage Recommendations for Hormone Therapy when Used at High Doses for Gender Transitioning56 Part IVPrevention and Management of Co-morbidities in PLWH57 Opioid Addiction58 Cancer: Screening Methods59 Cancer: treatment Monitoring60 Lifestyle Interventions61 Prevention of Cardiovascular Disease (CVD)62 Hypertension: Diagnosis, Grading and Management63 Hypertension: Drug Sequencing Management64 Drug-drug Interactions between Antihypertensives and ARVs65 Type 2 Diabetes: Diagnosis67 Type 2 Diabetes: Management68 Dyslipidaemia 69 treatment Goal for LDL-c for Very High and High CVD Risk Persons70 Bone Disease: Screening and Diagnosis71 Vitamin D Deficiency.

4 Diagnosis and Management72 Approach to Fracture Reduction in PLWH73 Kidney Disease: Definition, Diagnosis and Management74 ARV-associated Nephrotoxicity75 Indications and Tests for Proximal Renal Tubulopathy (PRT)76 Dose Adjustment of ARVs for Impaired Renal Function77 Work-up and Management of PLWH with Increased ALT/AST79 Liver Cirrhosis: Classification and Surveillance80 Liver Cirrhosis: Management81 Non-Alcoholic Fatty Liver Disease (NAFLD)82 Diagnosis and Management of Hepatorenal Syndrome / Acute Kidney Injury (HRS-AKI)83 Dose Adjustment of ARVs for Impaired Hepatic Function84 Lipodystrophy and Obesity: Prevention and Management85 Hyperlactataemia and Lactic Acidosis: Diagnosis, Prevention and Management87 Travel88 Drug-drug Interactions between Anti-malarial Drugs and ARVs89 Vaccination90 Sexual and Reproductive Health of PLWH91 Sexual Dysfunction 94 treatment of Sexual Dysfunction in PLWH95 Mental Health in PLWH: Depression and Anxiety Disorders96 Depression.

5 Screening and Diagnosis96 Depression: Management 97 Classification, Doses, Safety and Adverse Effects of Antidepressants98 Drug-drug Interactions between Antidepressants and ARVs99 Anxiety Disorders: Screening and Diagnosis100 Anxiety Disorders: Management101 Classification, Doses and Adverse Effects of Anxiolytics102 Drug-drug Interactions between Anxiolytics and ARVs103 Algorithm for Diagnosis & Management of Cognitive Impairment in PLWH without Obvious Confounding Conditions 104 Chronic Lung Disease in PLWH105 Drug-drug Interactions between Bronchodilators (for COPD) and ARVs106 Drug-drug Interactions between Pulmonary Antihypertensives and ARVs107 Managing Older PLWH108 Solid Organ Transplantation (SOT) in PLWH113 Drug-drug Interactions between Immunosuppressants (for SOT)

6 And ARVs114 Part VClinical Management and treatment of Viral Hepatitis Co-infections in PLWH115 General Recommendations for Persons with Viral Hepatitis/HIV Co-infection115 treatment and Monitoring of Persons with HBV/HIV Co-infection116 treatment and Monitoring of Persons with HCV/HIV Co-infection117 HCV treatment Options in HCV/HIV Co-infected Persons118 Drug-drug Interactions between Viral Hepatitis Drugs and ARVs119 Management of Recently Acquired HCV Infection in PLWH120 EACS EuropeanAIDS Clinical Society2 EACS GUIDELINES Values of Non-invasive Tests for the Detection of Advanced Fibrosis and Cirrhosis121 Hepatitis D and E in PLWH122 Part VIOpportunistic Infections and COVID-19123 When to start ART in PLWH with opportunistic Infections (OIs)123 Immune Reconstitution Inflammatory Syndrome (IRIS)

7 124 Primary Prophylaxis of OIs According to Stage of Immunodeficiency125 Primary Prophylaxis, treatment and Secondary Prophylaxis/Maintenance treatment of Individual OIs126 Diagnosis and treatment of TB in PLWH135TB Drug Doses138 Management of COVID-19 in PLWH139 Part VIIP aediatric HIV Treatment140 Initiation of ART in Children and Adolescents Living with HIV140 Initial Combination Regimen for ART-na ve Children and AdolescentsLiving with HIV140 Additional Specific Paediatric Considerations140 Adherence, Virological Failure and Second Line ART143 Virological Failure on Second Line Combination143 ReferencesVideo links144 References to All Sections145 EACS EuropeanAIDS Clinical Society3 EACS GUIDELINES to the EACS GUIDELINES 2021 Welcome to the EACS GUIDELINES !

8 These GUIDELINES were developed by the European AIDS Clinical Society (EACS), a not-for-profit organisation, whose mission is to promote excel-lence in standards of care, research and education in HIV infection and re-lated co-infections, and to actively engage in the formulation of public health policy, with the aim of reducing the HIV disease burden across EACS GUIDELINES were first published in 2005, and are currently avail- able, online as a pdf and web-based version, and as a free App for iOS and Android devices. The GUIDELINES are as of 2021 no longer produced as a printed booklet, but continue to be translated into several different languages.

9 The GUIDELINES undergo formal minor revisions annually and major revisions every second year. Interim updates may however also be provide at any time the panels consider it aim of the EACS GUIDELINES is to provide easily accessible and compre- hensive recommendations to clinicians involved in all aspects of care of people living with HIV (PLWH).The EACS GUIDELINES cover a relatively large and diverse area geograph-ically, with different national levels of access to care. As a natural conse-quence, the GUIDELINES aim to cover a relatively wide range of recommenda-tions as opposed to the often more uniform national 2021 version of the GUIDELINES includes updates of all existing sections but have also included an entirely new section on COVID-19 in PLWH and recommendations on paediatric ART developed in collaboration with Penta.

10 The most essential changes are listed in the Summary of changes from to Each respective section of the GUIDELINES is managed by a panel of expe-rienced European HIV experts, with additional experts in other fields of ex-pertise included where necessary. All recommendations are evidence-based whenever possible and based on expert opinions in the rare instances where adequate evidence is unavailable. The GUIDELINES do not provide formal grades of evidence, panels make decisions by consensus or by vote when necessary and we do not publish results of the votes or discrepancies if any EACS GUIDELINES panels are overseen by a GUIDELINES Chair who serves a three-year term and is elected from the Governing Board.