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IAS 2025 Asia Pacific
What IAS 2025 Means for HIV Care in the Asia-Pacific Region

Released: August 20, 2025

N. Kumarasamy
N. Kumarasamy, MBBS, FRCP, PhD
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Key Takeaways
  • Updates to the WHO HIV Treatment Guidelines recommend TAF as first-line treatment for HIV, DTG + 3TC for treatment simplification, and DRV/r as a preferred protease inhibitor option.
  • The IMPALA study demonstrated that LA CAB + RPV is safe and noninferior to DTG-based therapy for people with unsuppressed HIV.
  • Same-day ART for people with HIV and presumptive TB infections is safe and effective.

Among all the symposia, oral abstracts, and posters at International AIDS Society (IAS) 2025, I think the presentations from the World Health Organization (WHO) Treatment Guidelines update of 2025 will have the greatest immediate impact on my region of Asia and the Pacific Islands, and the lower-middle income countries in particular.

Updated WHO Treatment Guidelines
At this conference, WHO representatives outlined a few new recommendations. The first of these updates concerned the use of tenofovir disoproxil fumarate (TDF). TDF has long been a preferred drug of choice for first-line treatment of HIV. However, there are reports of chronic kidney disease and osteoporosis-related complications in people with HIV who are on long-term tenofovir-containing therapy. In the new 2025 guidelines, the WHO also recommend tenofovir alafenamide (TAF) as first-line treatment. Studies show that TAF seems to have lower renal toxicity compared to TDF. Although TDF is still a recommended first-line therapy, healthcare professionals can now consider choosing between TDF or TAF, depending on whether the person is at high risk for renal toxicity or is postmenopausal.

The updated recommendations on treatment simplification were also of interest. People who are already on a first-line antiretroviral therapy (ART) that contains TAF or TDF can be switched to a 2-drug regimen of dolutegravir (DTG) and 3TC if they have an undetectable viral load after 6 months of therapy. I think this is very important for avoiding ART-related adverse events, particularly in our region of Asia, where I have observed a high incidence of tenofovir-related toxicities.

The WHO guidelines were also updated for use of protease inhibitors (PI). The preferred PIs in resource-limited settings, including in the Asia-Pacific region, have historically been either atazanavir/ritonavir (ATV/r) or lopinavir/ritonavir (LPV/r). Published studies show that darunavir/ritonavir (DRV/r) is superior to ATV/r and LPV/r in both efficacy and tolerability. As such, DRV/r is now recommended as a preferred PI option, with ATV/r or LPV/r as an alternate option.

Long-acting ART
Also of interest to many was the IMPALA study, carried out in sub-Saharan Africa, which assessed long-acting injectable cabotegravir plus rilpivirine (LA CAB + RPV) for people whose HIV RNA is poorly controlled on first-line therapy. This study included 540 participants randomized into 2 different groups: One group received LA CAB + RPV every 2 months, and the other group received 2 NRTIs plus DTG, with a primary endpoint of HIV-1 viral load <50 copies/mL. The results showed that LA CAB + RPV every 2 months was noninferior to daily DTG-based therapy in people with unsuppressed HIV. 

There were 5 virologic failures in the LA CAB + RPV group. Sequencing revealed minor and intermediate mutations to integrase inhibitors in 4 out of 5 participants at the time of virologic failure. When these participants were put on once-daily oral therapy with tenofovir, lamivudine, and dolutegravir, all HIV RNA returned to undetectable levels.

Altogether, this regimen was found to be safe and effective. These results are very important, particularly for resource-limited settings in the Asia-Pacific region where adherence to oral daily therapies is poor. In addition, 94% of participants reported that they preferred a long-acting injectable therapy, as it would eliminate the stigma of taking oral therapy every day.

HIV and Coinfections
The final study I want to discuss concerns HIV and tuberculosis (TB) coinfection. TB remains a leading cause of death among people living with HIV, with approximately 45% of new TB infections per year occurring in the Asia-Pacific region. As such, data to inform strategies for management of HIV and TB coinfection are crucial.

The SaDAPT trial examined whether same-day ART initiation in people with HIV and presumptive TB diagnosis is safe and effective. The current WHO recommendation is that rapid ART initiation should be offered to people who are asymptomatic for TB. However, for symptomatic people, the current recommendations state that ART should be delayed to rule out all opportunistic infections. If the person has no neurologic opportunistic infection, ART can be started while testing for TB. 

Investigators of the SaDAPT trial recruited 590 participants with HIV and presumptive TB, who were randomized to 2 groups. One group started same-day ART while they were tested for TB. The other group waited to start ART until after TB diagnostic testing. Ultimately, investigators found no difference in terms of virologic suppression between the groups. They found an equal incidence of TB and incidence of TB immune reconstitution inflammatory syndrome in both groups.

These findings show that in people with HIV and presumptive TB, same-day ART initiation was noninferior to waiting to obtain TB diagnostic results first. These results will directly influence how we care for people in my region. Currently, we rule out TB or initiate TB treatment first. Then, after a week or 2, based on the current WHO guidelines, we initiate ART. Now, we know we can initiate ART the same day, without negative impact on TB treatment or HIV virologic suppression. Same-day ART initiation is critically important because you don't want to lose people out of care. So, starting people on treatment right away and engaging them in care and helps to retain patients in our healthcare system.

This conference very clearly showed the importance of newer antiviral therapies, with even more in the pipeline. This is a huge boon for people living with HIV in terms of maintaining a high quality of life and managing HIV as they would any other another chronic disease. However, there is a need to bring all those newer drugs to resource-limited settings as soon as possible, without delay, so that the maximum benefits will be obtained for all.

Your Thoughts
How will the new updates to the WHO guidelines for HIV affect your approach to treatment and prevention of HIV? What studies will be most immediately impactful for your practice? Leave a comment to join the discussion!

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