What is the treatment for influenza in patients with Human Immunodeficiency Virus (HIV)?

From the Guidelines

For individuals with HIV who have the flu, antiviral treatment with oseltamivir (Tamiflu) 75mg twice daily for 5 days is recommended, as it works best when started within 48 hours of symptom onset, and is supported by the most recent guidelines from 2019 1. The treatment approach should prioritize reducing the risk of complications from influenza, such as pneumonia, respiratory failure, and death, especially in immunocompromised patients like those with HIV. Key considerations include:

• Starting antiviral treatment as soon as possible, without waiting for diagnostic test results, as empiric treatment is often necessary 1.
• Using a single neuraminidase inhibitor, such as oseltamivir, zanamivir, or peramivir, and not combining them 1.
• Treating for 5 days, but considering longer duration for patients with immunocompromising conditions or severe lower respiratory tract disease 1.
• Maintaining antiretroviral therapy without interruption during flu illness to preserve immune function.
• Monitoring for potential interactions between antiretrovirals and flu medications.
• Watching for complications that require immediate medical attention, such as difficulty breathing, chest pain, or persistent high fever.
• Annual flu vaccination remains the best preventive measure for HIV-positive individuals, ideally before flu season begins.

From the Research

Treatment of Flu with HIV

• The treatment of flu in patients with HIV is crucial to prevent complications and reduce the risk of transmission 2, 3.
• Neuraminidase inhibitors such as oseltamivir and zanamivir have been shown to be effective in treating influenza A and B in patients with HIV 4, 5.
• Oseltamivir is an orally active neuraminidase inhibitor that can reduce the duration of symptomatic illness and hasten the return to normal levels of activity when initiated promptly in patients with naturally acquired influenza 2.
• Zanamivir and oseltamivir have been compared in several studies, with both drugs showing similar efficacy in reducing the duration of influenza-related symptoms 3, 5.
• Alternative regimens of neuraminidase inhibitors, such as intravenous peramivir, have also been evaluated for the treatment of influenza in hospitalized patients, with some studies suggesting that they may be effective in reducing the time to alleviation of fever 6.

Efficacy of Neuraminidase Inhibitors

• The efficacy of neuraminidase inhibitors in treating influenza in patients with HIV has been demonstrated in several studies, with reductions in the duration of symptomatic illness and the risk of complications 2, 3, 4.
• The use of neuraminidase inhibitors has also been shown to reduce the risk of transmission of influenza in household contacts of infected persons 2.
• However, the efficacy of neuraminidase inhibitors may be reduced in patients with underlying respiratory disease or other comorbidities, and alternative treatment regimens may be necessary in these cases 4, 6.

Safety and Tolerability

• Neuraminidase inhibitors such as oseltamivir and zanamivir have been shown to be generally well-tolerated in patients with HIV, with common adverse events including nausea, vomiting, and headache 2, 3, 5.
• The safety and tolerability of alternative regimens of neuraminidase inhibitors, such as intravenous peramivir, have also been evaluated, with some studies suggesting that they may be associated with a higher risk of adverse events 6.