Treatment guidelines in the United Kingdom continue to recommend that people living with HIV start antiretroviral (ARV) therapy when the CD4 cell count falls to 350 or below, though the preliminary version released February 4 and reviewed by aidsmap also recommends that health care providers discuss the evidence that treatment reduces the risk of HIV transmission at any CD4 level.  

The new U.K. guidelines also make a clear recommendation on the two nucleoside drugs that should be used as the basis of first-line antiretroviral treatment: Tenofovir and emtricitabine, often used together as Truvada and in other fixed-dose combination tablets. 

“After rigorous review of the published evidence, British doctors have concluded that the U.K. will stick with a CD4 cell count of 350 cells as the threshold for starting treatment in the majority of patients,” the aidsmap report reads. The U.K. guidelines contrast with HIV treatment guidelines in the United States, last updated in October 2011, recommending treatment for all people living with HIV with CD4 counts up to 500 cells. 

For U.K. residents living with HIV who have CD4 cell counts above 350 and want to begin therapy to reduce the risk of transmitting HIV—supported by clinical trials like HPTN 052, demonstrating a 96 percent reduction in the risk of transmitting the virus among HIV-serodiscordant heterosexual couples—the British HIV Association (BHIVA) indicates that these individuals should be allowed to do so. 

The BHIVA guidelines also recommend treatment for certain individuals with CD4s above 350, notably those with AIDS-defining illnesses, HIV-related kidney disease (nephropathy), hepatitis B or hepatitis C coinfection, tuberculosis or non-AIDS cancer requiring immune-suppressive treatment. 

As for what to include in a first-line treatment regimen, tenofovir plus emtricitabine is now the only “preferred” nucleoside reverse transcriptase inhibitor combination for use in combination with a third ARV. Abacavir plus lamivudine, sold in the United Kingdom as Kivexa and the United States as Epzicom, which enjoyed preferred status in the 2008 BHIVA guidelines, is now listed as an “alternative” option, though it should be avoided by those with assumed hypersensitivity to the drug (confirmed via HLA-B*5701 testing), viral loads above 100,000 copies and high cardiovascular disease risk.

Similar to the U.S. treatment guidelines, preferred third drugs in the United Kingdom to be used in combination with tenofovir and emtricitabine include efavirenz—all three ARVs are available as the fixed-dose combination tablet Atripla in the United Kingdom—Isentress (raltegravir), Norvir (ritonavir)-boosted Reyataz (atazanavir) or Norvir-boosted Prezista (darunavir). Previously, aidsmap notes, BHIVA had recommended efavirenz as the only “preferred” option.