EACS Guidelines 2025: HIV updates put comorbidities first — ART on cruise control

PARIS, October 17, 2025 — The European AIDS Clinical Society (EACS) has shifted the focus of its guidelines toward managing comorbidities and the health needs of an aging HIV population, while making only incremental changes to first-line antiretroviral therapy (ART). Version 13.0, unveiled here at the 20th European AIDS Conference and published in HIV Medicine, expands guidance on vaccination, cardiovascular risk, cancer screening, mental health, and prevention.

“They don’t only cover HIV treatment and management of co-infections, but also deal with comorbidities, which are becoming more and more important in an aging population living with HIV,” said Jürgen Rockstroh, MD, head of infectious diseases at University Hospital Bonn, Germany, and chair of the EACS Guidelines, speaking with Medscape Medical News. Rockstroh noted that the guidelines offer practical targets and tools for HIV physicians who often manage comorbidities without support from other specialists.

ART: Evolution, Not Revolution

• First-line therapy remains largely unchanged, continuing to prioritize second-generation integrase inhibitors, with doravirine retained as an option in the absence of head-to-head trials vs second-generation integrase–based regimens, Rockstroh said.
• For individuals who acquire HIV while on long-acting cabotegravir PrEP, the guidelines recommend initiating a triple regimen including boosted darunavir and advise against dual therapy.
• A new section covers HIV-2 — when to suspect, diagnose, treat, and monitor — reflecting rising encounters in Europe due to migration, with higher prevalence in people with links to West Africa.

Prevention and PrEP

• Version 13.0 integrates long-acting injectable PrEP options (cabotegravir and lenacapavir) and recommends HIV RNA testing before starting PrEP in those with recent high-risk exposure or when using long-acting agents.
• For postexposure prophylaxis in someone already using oral PrEP, the guidance advises taking two tablets of the oral PrEP regimen as soon as possible after exposure, followed by one tablet daily until medical evaluation.

Vaccination: RSV and a Major Hepatitis B Overhaul

• The RSV vaccine is now recommended for people aged 75 years or older.
• The hepatitis B vaccination section is substantially revised. New CpG-adjuvanted vaccines enable near-100% response rates in people living with HIV, including prior nonresponders, Rockstroh said, while noting that reimbursement remains inconsistent across Europe.
• With growing use of two-drug or long-acting regimens that often lack tenofovir disoproxil fumarate/tenofovir alafenamide (TDF/TAF), vaccination status becomes more critical because switching away from TDF/TAF removes the protective effect against HBV.
• People with past HBV infection can move to two-drug or long-acting regimens with careful monitoring; intermittent, very low-level HBV DNA has been reported, but no cases of hepatic decompensation have been noted. The guidelines detail monitoring parameters.

Pregnancy and Children

• Bictegravir/emtricitabine/tenofovir alafenamide has been added to the options in pregnancy and is commonly used, said Rockstroh.
• The guidelines add more detail on viral load monitoring during pregnancy, based on adherence and pre-pregnancy viral load. “Elective Caesarean section should be planned at week 38 if the viral load at week 36 is greater than 400 cp/mL,” said Laura Levi, MD, of Hôpital Bicêtre, Paris, who presented the pregnancy updates. If HIV is diagnosed during labor, start ART as soon as possible, including a last-generation integrase inhibitor and intravenous zidovudine.
• For children and adolescents, licensing updates, newer formulations, and guidance on transitioning to adult care are included, addressing a vulnerable period for treatment continuity.

Co-infections, Opportunistic Infections, and Cancer Screening

• The opportunistic infections section updates tuberculosis terminology — distinguishing “tuberculosis infection” from “tuberculosis disease,” provides new dexamethasone dosing recommendations for central nervous system involvement, and revises guidance on tecovirimat for mpox. Trials (UNITY, PALM0072, STOMP3) showed no efficacy of tecovirimat against mpox, said Andrea Mastrangelo, MD, CHUV, Lausanne University Hospital, Switzerland. Tecovirimat is considered safe; for severely immunocompromised individuals or severe/protracted mpox, evidence for antivirals is nonconclusive. The emphasis is on optimizing immune function; antivirals may be considered case by case.
• Cancer screening recommendations are updated for hepatocellular carcinoma (HCC), prostate, anal, breast, cervical, and lung cancers. For HCC, criteria aligned with the European Association for the Study of the Liver recommendations now omit ethnicity and region. Implementation remains a challenge: Access to ultrasound is a bottleneck, and routine HCC screening rates are around 66%, Rockstroh said.

Cardiovascular and Metabolic Health

• Cardiovascular risk management is emphasized in the updated guidelines. Following the REPRIEVE study, there is momentum to initiate statins earlier — particularly in those over 40 — and to intensify lipid control. Benefits may extend beyond LDL lowering, with potential anti-inflammatory effects of statins, Rockstroh noted.
• The hypertension intervention threshold is lowered to 129 mm Hg, aligning with the 2024 European Society of Cardiology guidelines.
• Obesity guidance is extensively rewritten, addressing weight trends linked to return-to-health, newer regimens, and lifestyle factors; it covers lifestyle measures, pharmacotherapy, and bariatric options. GLP-1 agonists are discussed, though evidence in people with HIV remains limited.

Mental Health and Substance Use

• New screening and practical tools include suicide-risk screening with the Ask Suicide-Screening Questions and guidance on alcohol and chemsex-related harms.
• A new drug–drug interaction table links antiretrovirals with recreational substances. The guidelines propose a simple screening question followed by the Alcohol, Smoking and Substance Involvement Screening Test tool for detection and brief intervention.
• New sections address sleep health and introduce a unified substance-use framework.

“These guidelines help clinicians manage people who are getting older and developing comorbidities,” Rockstroh said, underscoring that they provide clear targets for blood pressure and LDL, identify who should receive statins and cancer screening and when, and embed simple mental-health tools alongside treatment guidance.

By Becky McCall, MSc, MScPh