Update of treatment guidelines for HIV infection recommended by experts

An evaluation of the latest information on the treatment of the adult human immunodeficiency virus (HIV) has led an international panel of experts to update the guidelines and recommendations for antiretroviral treatment of HIV.

The International AIDS Society panel led by Dr. Scott M. Hammer from Columbia University College of Physicians and Surgeons, New York, say antiretroviral therapies continue to evolve rapidly which means treatment guidelines must also be continually refined to guarantee the highest possible standard of care and treatment can be delivered.

They say the availability of new antiretroviral drugs, new formulations and new data have transformed a disease which was fatal to one which can be managed and the guidelines need updating in key areas of HIV management.

Dr. Hammer and the panel analysed data from the last two years in order to provide guidelines including when to start therapy, choice of initial regimens, patient monitoring, and the approach to treatment failure.

They say antiretroviral therapy should start before the CD4 cell count drops to less than 350/ìL but factors and risks should also be considered... in particular the presence of other existing illnesses and they say the initial regimen must be individualized to allow for such issues.

They say the simplicity of the therapy, the number of pills, tolerability, desire for pregnancy, drug interactions and primary drug resistance are likely to influence the choice of therapy option.

Antiretroviral therapy aims to reduce and maintain a plasma HIV-1 RNA level of less than 50 copies/mL and the panel say these levels should be monitored frequently when treatment is started or changed for virologic failure, until satisfactory levels are achieved and then regularly checked 3 to 4 times a year.

Some patients will also need to be tested for drug resistance and monitored for toxicity before starting treatment and during follow-up.

If initial treatment appears to be failing they say the drug regimen should be changed and where the disease is multi-drug resistance, three active drugs, including new classes of agents whenever possible, should be used.

They say new agents, such as raltegravir, maraviroc and etravirine, in combination with older drugs can help patients with high degrees of treatment experience and a multidrug resistant virus.

The panel say despite advances in the treatment of HIV infection, disease management remains challenged by toxicities, maintaining the treatment and manifestations related to both the drugs and the HIV infection itself.

They say the threat of drug resistance means a robust drug development pipeline must be sustained so that effective therapies and monitoring tools are available.

The panel suggest that creativity and political will regarding antiretroviral therapy in the developed world, can be applied to public health approaches in the developing world, where 90 percent of the world's HIV-infected population lives.

The recommendations of the panel appear in the August 6 issue of JAMA, the Journal of the American Medical Association.