NICE vs BASHH: Management of HIV (2025)

Introduction

The management of HIV in the United Kingdom is primarily guided by two key bodies: the National Institute for Health and Care Excellence (NICE) and the British Association for Sexual Health and HIV (BASHH). While their overarching goal is identical—to optimise health outcomes for people living with HIV—their guidelines serve distinct purposes. NICE guidelines provide a comprehensive, evidence-based framework intended for a national audience, including commissioners and non-specialist clinicians, often with a focus on health economic impact. In contrast, BASHH guidelines are typically more detailed, practitioner-focused documents written by specialists for specialists, offering granular advice on complex clinical scenarios. This comparison for 2025 delineates the key similarities and differences between these two essential resources to aid clinicians in their practice.

See how this translates to practice: Explore our Clinical governance features, visit the Patient Safety Hub, or review Clinical Safety & Assurance for enterprise rollout.

Diagnosis and Initial Assessment

NICE Guideline NG168 (Updated 2021, still current in 2025)

NICE adopts a public health and primary care perspective, emphasising increasing testing uptake to reduce undiagnosed HIV.

• Testing Recommendations: Advocates for routine opt-out testing in areas with a high HIV prevalence (≥2/1000) in all general medical admissions and registrations at GP practices and emergency departments. Also recommends targeted testing for key populations regardless of location.
• Confirmatory Testing: Stipulates that a reactive point-of-care test must always be confirmed by a laboratory-based serological assay.
• Initial Assessment: Focuses on the core components: confirming diagnosis, obtaining baseline CD4 count and HIV viral load, conducting a full STI screen, and assessing co-morbidities and psychosocial needs. It highlights the importance of a multidisciplinary approach.

BASHH Guideline (2025, aligns with BHIVA/BASHH Standards)

BASHH provides the detailed "how-to" for specialists in sexual health and HIV clinics.

• Testing Recommendations: Assumes a clinical setting where HIV is a core focus. Provides detailed algorithms for testing, including the use of 4th generation antigen/antibody assays and the management of indeterminate or discrepant results.
• Baseline Investigations: Offers a more exhaustive list of baseline tests. This includes HLA-B*5701 testing (for abacavir hypersensitivity risk), coreceptor tropism assay (if a CCR5 inhibitor is considered), and hepatitis A immunity status. BASHH gives specific guidance on the interpretation of these results in the context of treatment initiation.
• Resistance Testing: Strongly mandates the use of a baseline HIV drug resistance test before ART initiation, and provides detailed guidance on its interpretation.

Key Difference: NICE drives the "where and why" of testing to maximise diagnosis, while BASHH details the "how" of confirmation and specialist baseline assessment.

Antiretroviral Therapy (ART)

NICE Guideline

NICE's approach to treatment is heavily influenced by health technology appraisals (HTAs), which assess the cost-effectiveness of drugs.

• When to Start: Recommends ART for all people living with HIV, regardless of CD4 count, aligning with international standards (the "Treat All" approach).
• What to Start: The recommended first-line regimens are those that have undergone a NICE HTA. For 2025, this typically includes integrase strand transfer inhibitor (INSTI)-based regimens such as dolutegravir/lamivudine or bictegravir/emtricitabine/tenofovir alafenamide (TAF) for appropriate patients. NICE may have specific restrictions or recommendations based on cost-effectiveness that may not perfectly mirror international clinical preference.
• Monitoring: Recommends viral load testing at 4-8 weeks after initiation, then every 3-6 months once suppressed, and CD4 monitoring less frequently in stable patients.

BASHH/BHIVA Guideline

BASHH, often in partnership with the British HIV Association (BHIVA), produces guidelines that are purely clinically focused, reflecting international expert consensus.

• When to Start: Also strongly recommends ART for all, immediately following diagnosis where possible.
• What to Start: Provides a more nuanced list of preferred and alternative regimens. The 2025 guidelines will likely continue to favour INSTI-based regimens but may offer more choices (e.g., including specific boosted PI options for certain situations) based on latest clinical evidence, without being constrained by a formal cost-effectiveness analysis for each option.
• Monitoring: Offers more detailed monitoring schedules, including guidance on managing virological blips, suspected treatment failure, and toxicity monitoring for specific drugs.

Key Difference: NICE's ART recommendations are shaped by national cost-effectiveness criteria, whereas BASHH/BHIVA guidelines are driven by latest clinical evidence and international consensus, potentially offering a broader range of "preferred" options.

Special Situations

NICE Guideline

NICE covers common co-morbidities and situations but at a higher level.

• TB/HIV Co-infection: Recommends coordinated care and outlines principles for managing drug interactions.
• Pregnancy: Recommends ART for all pregnant women and discusses the goal of viral suppression to prevent vertical transmission.
• Post-Exposure Prophylaxis (PEP): Provides guidelines for both occupational and non-occupational PEP.

BASHH Guideline

BASHH provides extensive, detailed guidance on complex scenarios.

• TB/HIV Co-infection: Provides specific ART regimens and timing in relation to TB therapy, detailed management of immune reconstitution inflammatory syndrome (IRIS), and adjustment for drug-resistant TB.
• Pregnancy: Offers detailed advice on preferred ART regimens in pregnancy, dosing changes, management of nausea, and rapid initiation pathways for women presenting late in pregnancy.
• Pre-Exposure Prophylaxis (PrEP): BASHH, in conjunction with BHIVA, is the primary source for detailed UK guidance on PrEP, including eligibility, monitoring, and management of breakthrough infections.

Key Difference: For complex co-infections and specialised prevention like PrEP, BASHH guidelines are the definitive, detailed UK resource for clinicians managing these situations day-to-day.

Practical Clinical Flow and Takeaways

For a clinician, integrating both guidelines creates an efficient pathway:

1. Diagnosis: Follow NICE's public health advice on who to test. Use BASHH's laboratory protocols for how to confirm the diagnosis.
2. Referral & Baseline Assessment: Refer all newly diagnosed patients to a specialist HIV service. The specialist will conduct the comprehensive baseline assessment as per BASHH/BHIVA standards.
3. Treatment Initiation: The choice of first-line ART in a UK clinic will be a synthesis of NICE's HTA-approved options and the broader preferred regimens within BASHH/BHIVA guidelines. Local hospital drug formularies will reflect this balance.
4. Ongoing Management: Use the detailed monitoring, toxicity management, and special situation advice from BASHH/BHIVA for specialist care. NICE provides the overarching principles suitable for shared care with GPs.

Practical Takeaway: Think of NICE as setting the national standard and framework, while BASHH/BHIVA provides the specialist's detailed manual for implementation.

Frequently Asked Questions (FAQs)

1. Which guideline takes precedence if they differ?

In practice, for specialist HIV care, the BASHH/BHIVA guideline typically takes precedence on matters of detailed clinical management as it is more current and specific. However, for commissioning services, testing policies, and drug funding approvals, NICE guidelines have formal weight. Most often, they are complementary rather than contradictory.

2. I'm a GP. Which guideline is most relevant for me?

NICE is your primary resource. It guides you on when to offer testing and provides the essential information for shared care, such as monitoring stable patients and managing common co-morbidities. Refer to BASHH/BHIVA for deeper understanding or when managing complex cases in conjunction with a specialist.

3. How frequently are these guidelines updated?

BASHH/BHIVA guidelines are typically updated more frequently (e.g., every 2-3 years or in response to major new evidence) to reflect rapid advancements in HIV medicine. NICE guideline updates are often a longer process due to their comprehensive evidence reviews and health economic assessments.

4. Where can I find the most up-to-date ART recommendations?

The BASHH/BHIVA website hosts the definitive UK ART guidelines. These are updated regularly and are considered the gold standard for clinical practice by HIV specialists. NICE's HTA documents for specific drugs should be checked for funding and approval status.

5. Do the guidelines differ on the use of PrEP?

NICE recommends PrEP as an effective intervention for high-risk groups. However, the detailed clinical guidance on how to deliver PrEP—including eligibility, monitoring, and follow-up—is exclusively covered in the BASHH/BHIVA PrEP guideline, which is the essential document for any service providing PrEP.

Source Links

• NICE Guideline NG168 (HIV testing and prevention): NICE NG168
• NICE Topic Page on HIV: NICE HIV topic hub (Includes links to relevant Technology Appraisals for ART drugs).
• BASHH Guidelines Index: BASHH guidelines
• BHIVA Guidelines: BHIVA guidelines (The primary source for UK ART and management guidelines, produced in partnership with BASHH).