Antiretroviral Guidelines

US DHHS Guidelines with Australian commentary

HIV-2 Infection

Last Updated: July 10, 2019; Last Reviewed: July 10, 2019

Summary of HIV-2 Infection

AU comment: HIV-2 Infection

Summary of HIV-2 Infection

  • The clinical course of HIV-2 infection is generally characterized by a longer asymptomatic stage, lower plasma viral loads, and lower mortality rate than HIV-1 infection. However, progression to AIDS and death will occur in the majority of individuals without treatment.
  • No randomized controlled trials have addressed when a person with HIV-2 should start antiretroviral therapy (ART) or which regimens are most effective for initial or second-line ART when treating HIV-2; thus, the optimal treatment strategy is not well defined.
  • Existing data on the treatment of HIV-2, and extrapolation from data on the treatment of HIV-1, suggest that ART should be started at or soon after HIV-2 diagnosis to prevent disease progression and transmission of HIV-2 to others (AIII).
  • Quantitative plasma HIV-2 RNA viral load testing for clinical care is available and should be performed before initiation of ART (AIII).
  • HIV-2 is intrinsically resistant to non-nucleoside reverse transcriptase inhibitors and to enfuvirtide; therefore, these drugs should not be included in ART regimens for HIV-2 infection (AII).
  • Patients with hepatitis B virus (HBV)/HIV-2 coinfection should be prescribed ART regimens that contain drugs with activity against both HIV-2 and HBV (AIII).
  • Initial ART regimens for ART-naive patients who have HIV-2 monoinfection or HIV-1/HIV-2 coinfection should include an integrase strand transfer inhibitor (INSTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs) (AII). An alternative regimen is a boosted protease inhibitor (PI) that is active against HIV-2 (darunavir or lopinavir) plus two NRTIs (BII).
  • HIV-2 RNA, CD4 T lymphocyte (CD4) cell counts, and clinical status should be used to assess treatment response (AIII). Unlike persons with HIV-1, persons with HIV-2 should continue to undergo periodic CD4 cell count testing even if their viral loads are persistently suppressed, because disease progression can occur despite an undetectable viral load.
  • Resistance-associated viral mutations to INSTIs, PIs, or NRTIs may develop in persons with HIV-2 while they are on ART. However, no validated HIV-2 genotypic or phenotypic antiretroviral resistance assays are approved for clinical use.
  • In the event of virologic, immunologic, or clinical failure, a new ART regimen should be constructed in consultation with an expert in HIV-2 management.
Rating of Recommendations:  A = Strong; B = Moderate; C = Optional
Rating of Evidence:  I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion