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Treatment of HIV Infection: Updated Guidelines from the IAS–USA

The panel recommends that HIV-infected patients with CD4 counts <350 cells/mm³ be treated and that therapy be considered in patients with higher CD4 counts.

Target Population: Physicians and other caregivers who treat adults with HIV infection

Sponsoring Organization: International AIDS Society–USA

Type: Evidence-based consensus guidelines using a categoric rating system

Key Points: This document updates guidelines that were last revised in 2006. The new guidelines recommend that symptomatic patients, and asymptomatic patients with CD4 counts <350 cells/mm³, receive antiretroviral therapy (ART). In addition, based on evidence of increased risk for non–AIDS-defining conditions (e.g., cardiovascular, renal, or hepatic disease; non–AIDS-related cancers) in HIV-infected persons, therapy should be considered for patients who have CD4 counts >350 cells/mm³, especially if they have comorbidities or risk factors for rapid progression. This group includes patients with HIV RNA levels >100,000 copies/mL, rapidly declining CD4 counts (loss >100 cells/mm³ per year), hepatitis B or C virus infection, HIV-associated nephropathy, or risk factors for cardiovascular disease. Therapy should be initiated with tenofovir/emtricitabine or abacavir/lamivudine, plus either efavirenz or a ritonavir-boosted protease inhibitor (lopinavir, atazanavir, fosamprenavir, darunavir, or saquinavir). In patients who have multidrug-resistant HIV, the goal of therapy should be complete suppression of viral replication through the use of new agents such as raltegravir, maraviroc (in persons with CCR5-tropic virus), and second-generation protease and nonnucleoside reverse-transcriptase inhibitors.

Comment: Like the guidelines released by the U.S. Department of Health and Human Services during the past year, these guidelines confirm that the pendulum has swung firmly toward earlier initiation of ART in HIV-infected patients. What has pushed the pendulum in this direction is the improved tolerability of newer ART regimens together with the realization that uncontrolled viral replication is associated with increased risk for non–AIDS-defining conditions. Earlier treatment of HIV-infected patients with comorbidities or risk factors for progression might reduce the burden of non–AIDS-related disease, although such a reduction remains to be proven.

The guidelines also reiterate that the goal of therapy for all HIV-infected patients should be complete viral suppression. Although this goal has long been attainable for patients initiating treatment, it is also now realistic (because of the availability of new agents) for most patients with drug-resistant HIV. Expanding HIV testing programs continues to be of paramount importance, as does ensuring that patients are ready to initiate therapy so that optimal adherence can be achieved.

— Rajesh T. Gandhi, MD

Published in Journal Watch Infectious Diseases August 27, 2008

Citation(s):

Hammer SM et al. Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society–USA panel. JAMA 2008 Aug 6; 300:555.

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