Summary

People in London who are starting HIV treatment for the first time will now normally be prescribed a combination of drugs based on Kivexa (abacavir/3TC) unless there is a clinical reason not to prescribe it.

People will be offered efavirenz (Sustiva) as the first option alongside Kivexa, with nevirapine (Viramune) or atazanavir (Reyataz) as alternative options.

Reasons not to prescribe Kivexa include having a viral load over 100,000 copies/ml, a positive genetic test for hypersensitivity to abacavir, having HIV that is resistant to one of the drugs, or being at high risk of a heart attack in the next ten years.

Therapy based on Truvada (tenofovir/FTC) will generally be prescribed in these situations. Truvada will also be given to people with hepatitis B, and those being treated for hepatitis C.

People who start therapy with a protease inhibitor will now normally be given atazanavir (Reyataz) boosted by ritonavir (Norvir). Patients who are already taking a protease inhibitor may be assessed to see if they can change to atazanavir. Darunavir (Prezista) is recommended as the alternative PI for patients who have resistance to atazanavir or cannot tolerate it. The latter group might include people on a group of drugs called PPIs (used to treat acid reflux and ulcers) because of the risk of interaction, and people with a history of kidney stones.

The integrase inhibitor raltegravir (Isentress) will only be used in very specific circumstances: short-term use in first-line treatment for patients with very complex drug interactions, or for pregnant women diagnosed with HIV late in pregnancy, where there is a need for very rapid viral load reduction.

It has been emphasised that no patient will be given sub-optimal treatment or therapy that involves a risk of serious side-effects.

The change in prescribing practice for first-line treatment will not initially affect patients on current regimens but will be applied to new patients and to patients who need to change to a second-line protease inhibitor-based regimen. It has now been confirmed that patients will not be compelled to change from their current treatment against their will.

The decision was made by the London HIV Consortium Drugs & Treatments sub-group after primary care trusts in London told HIV prescribers that their budget would not grow this year. This meant that hospitals needed to save £9 million on drugs in order to accommodate other HIV patient and clinic costs. HIV patient numbers rose by 5.3% in London in 2009 alone.

Additional cost savings can be made by greater use of 'home' delivery of anti-HIV drugs.

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Questions, concerns or looking for more information?

If you're concerned about these changes, or how they might affect your treatment and care, it's a good idea to talk to your doctor, or someone else in your healthcare team.

If you would like to talk it over with someone who doesn't work at your clinic, you could contact your local HIV support organisation, or an HIV helpline.

  • The Terrence Higgins Trust helpline, THT Direct, is available Monday to Friday 10am to 8pm on 0808 802 1221.
  • The HIV i-Base phoneline is available Monday to Wednesday noon to 4pm, on 0808 8006 013.

If you are concerned that you are being asked to change treatment inappropriately, then contact one of these helplines for advice.

We will add more information to this page as it becomes available.

If you think there are other aspects of the changes to prescribing that we should cover, or other information you would find useful, please contact us by emailing info@nam.org.uk or filling in the online contact us form.

Question from a reader via Twitter: "Is that good or bad news for people being prescribed?"

The changes to prescribing guidelines have come about because the NHS in London needs to reduce the amount of money it spends. It’s difficult to see that as good news.

However, the response from the London clinics, and the London HIV Consortium, has been to try to protect front-line services (keeping clinics open and staffed, for example) by reducing their spending on antiretroviral drugs. They have negotiated lower prices by agreeing some changes in how treatment is prescribed.

For many people with HIV in London, the changes will not affect them at all. Their treatment will stay the same. For people starting treatment for the first time, or changing treatment, the new guidance is clear that treatment should still be individualised. Nobody should be prescribed a drug that isn’t right for them just because it is cheaper.

Some people with HIV, and the organisations supporting them, are concerned about whether the guidelines will be followed properly, and whether the changes will be explained properly. If doctors are put under pressure to prescribe drugs they don’t think are appropriate, if people are prescribed drugs that are not medically appropriate for them, or if they have their treatment changed against their will or without adequate consultation – that would be bad news.

The key issue is that doctors and patients should still be working together to find the best possible treatment for each individual.

And if the drugs are bought at a cheaper price, protecting front-line services – and without compromising patient care? It’s difficult to see that as bad news.