European guidelines widen access to two-drug HIV treatment

More people with HIV can be considered for two-drug treatment either with dolutegravir / lamivudine or injectable cabotegravir / rilpivirine, according to updated European AIDS Clinical Society (EACS) guidelines presented on Monday at the International Congress on Drug Therapy in HIV Infection (HIV Glasgow 2026).

The new guidelines open up treatment with dolutegravir / lamivudine (Dovato) to people with high viral load, and people with suppressed viral load who have a history of resistance to lamivudine. Pregnant women and children over the age of two should also be able to take dolutegravir / lamivudine if they have suppressed viral load, the new guidelines recommend.

Presenting the updated antiretroviral treatment guidelines, Dr Annalisa Marinosci of Geneva University Hospital said that EACS guidelines no longer restrict the use of dolutegravir / lamivudine to people with viral load below 500,000 copies. The two-drug combination can be used by people starting treatment with higher viral loads unless they are experiencing primary infection, in which case a three-drug combination should be used to maximise the speed of viral load reduction and reduce the risk of drug resistance.

An analysis of two clinical trials has shown that dolutegravir / lamivudine is just as effective in people with high or very high viral load (above 500,000 copies/ml) as at lower viral load levels.

Past guidelines recommended that people who had previously developed resistance to lamivudine should not switch to dolutegravir / lamivudine, even with suppressed viral load, due to a potential risk of viral rebound. But the new guidelines say that people with historical M184V resistance associated with lamivudine should not be discouraged from switching to the two-drug combination if they have suppressed viral load and no evidence of resistance to an integrase inhibitor. Professor Alexandra Calmy of Geneva University Hospital, a member of the guidelines group, said that the accumulating evidence from analyses of people with the M184V mutation who have switched to dolutegravir / lamivudine shows that the risk of viral rebound is very low.

The new guidelines also recommend that women with suppressed viral load who are taking dolutegravir / lamivudine should not switch from the combination when they learn they are pregnant. But pregnant women who are not already on treatment are not recommended to start with the two-drug combination.

Dolutegravir / lamivudine is also suitable for children over the age of two years and weighing more than 10kg if they have suppressed viral load, the new guidelines recommend. The PENTA 21 study presented earlier this year showed that dolutegravir / lamivudine was non-inferior to two-drug treatment in 2-12 year olds, with no difference in the emergence of resistance upon treatment failure. 

For people starting cabotegravir / rilpivirine, the guidelines now recommend that there is no need for oral lead-in dosing unless there are concerns about tolerability. Instead, people eligible for injectable cabotegravir / rilpivirine should begin treatment with injections.

The panel reviewed the evidence on the use of injectable cabotegravir / rilpivirine in people with unsuppressed HIV. They recommended that it can be used in carefully selected cases – people with unsuppressed viral load need to experience adherence difficulties, not have resistance to rilpivirine or cabotegravir and be able to attend consistently for injections and virological monitoring.

Other antiretroviral recommendations include further downgrading of the older antiretrovirals abacavir and efavirenz to reflect concerns about cardiovascular risk and neuropsychiatric complications, respectively. Abacavir has been downgraded from a preferred to alternative option for adolescents.

For people with HIV and TB taking rifampicin, efavirenz has been downgraded and instead, the guidelines prefer twice-daily dolutegravir combined with either form of tenofovir and lamivudine or emtricitabine. The integrase inhibitors raltegravir or bictegravir may be used as alternatives to dolutegravir. Lopinavir / ritonavir is no longer recommended for use during TB treatment.

References

European AIDS Clinical Society. EACS guidelines: summary of changes. Last updated 23 October 2026.