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HIV Treatment Guidelines

September 4, 2015

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HIV Treatment Guidelines

Table of Contents


What Are Treatment Guidelines?

US Guidelines

A branch of the US government, called the Department of Health and Human Services, (DHHS), has put together a set of HIV treatment guidelines. The guidelines provide a lot of useful information to help health care providers and people living with HIV make decisions about when to start, when to stop, and when to change HIV medications. It also helps providers and people living with HIV (HIV+) choose among the many available HIV drugs.

The US DHHS provides several different treatment guidelines related to HIV care. These include the Perinatal Guidelines, the Treatment of Opportunistic Infections Guidelines, and the Pediatric Antiretroviral Treatment Guidelines. This article discusses only the recommendations contained within the Guidelines for Antiretroviral Treatment in Adults and Adolescents.

The DHHS guidelines are written and reviewed regularly by a group of HIV experts, including researchers, health care providers, and community activists. They were first published in 1998 and have been updated many times since then. The most recent guidelines were released in April 2015. The full version of the guidelines is available at http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf. Some of the important updates in the most recent version of the DHHS guidelines for the treatment of HIV in adults and adolescents are listed below.

Global Guidelines

The World Health Organization (WHO) released new HIV treatment guidelines in June 2013 at the International AIDS conference in Malaysia. Based on the results of recent studies, however, the WHO is expected to issue new HIV treatment guidelines late in 2015 that recommend HIV treatment for all people living with HIV, regardless of their CD4 count. Researchers have shown that people living with HIV who start treatment earlier, while their CD4 counts are still high, have a much lower risk of illness and death.

The June 2013 WHO guidelines recommend that HIV drugs be offered to all those living with HIV whose CD4 count is less than 500. It also recommends that HIV drugs be offered to certain groups as soon as they test positive for HIV. These include:

  • Women who are pregnant or breastfeeding
  • People living with HIV whose regular sexual partners are HIV-negative
  • People with active tuberculosis (TB)
  • People with hepatitis B and severe chronic (long-term) liver disease
  • Children younger than five years of age


Treatment Goals

The guidelines describe the goals of HIV treatment. They are basically to keep you as healthy and as well as possible using the best care and treatment available today. The goals are the same for people just starting treatment and those who have been on treatment for a long time:

  • Preserve or improve the health of your immune system by increasing your CD4 cells
  • Get your viral load as low as possible for as long as possible
  • Improve your quality of life and reduce illness and death
  • Reduce your risk of spreading HIV to others (also known as Treatment as Prevention), including sexual partners and babies (through perinatal transmission, or mother-to-child transmission)


Key Changes in the Revised April 2015 US DHHS Guidelines

Some of the important updates in the most recent version of DHHS guidelines for the treatment of HIV in adults and adolescents are listed here:

  • Changes to the list of 'recommended' and 'alternative' treatment regimens for those who have never taken HIV drugs before ("treatment naive"), regardless of baseline viral load or CD4 count; for specifics on these changes, see the section below on What to Start With)
  • New guidance for providers on the clinical management of people living with HIV for whom first and second treatment regimens fail
  • The addition of information on the use of HIV drugs with new drugs for hepatitis C treatment
  • New tables providing information on HIV drug interactions

More information on what the guidelines recommend is included below.


When to Start Treatment?

There has been a lot of discussion and debate about when to start treatment over the years, especially for people living with HIV who are relatively healthy (have high CD4 counts and no signs of ill health). The guidelines have been changed a number of times. Some earlier versions recommended that people wait longer before starting HIV treatment. This was because of concerns about the HIV drugs, such as side effects and difficult dosing schedules. It was thought that HIV was not as harmful as possible drug side effects in people with higher CD4 counts. We now understand that this is not true.

The results of a recent study (the START trial) have definitively shown that people living with HIV who start treatment earlier, while their CD4 counts are still high, have a much lower risk of illness and death. This includes people living with HIV who may have no outward signs of ill health. The study showed that taking HIV drugs earlier reduced the likelihood of developing not only AIDS-related illnesses, but also non-AIDS related illnesses.

With the results of the START trial, it appears clear that the benefits of starting treatment early outweigh any potential risks. Consequently, scientific experts and policy makers came together in July 2015 and issued a consensus statement declaring that all people living with HIV should have access to HIV treatment as soon as they are diagnosed. This statement was supported by agencies such as the International AIDS Society, the US President's Emergency Plan for AIDS Relief (PEPFAR), and UNAIDS, among others.

Also, newer drug combinations now available are easier to take and have fewer side effects than older regimens. For all these reasons the newest guidelines recommend starting HIV treatment as soon as someone is diagnosed.

The current US guidelines state:

  • HIV treatment is recommended for anyone who is living with HIV, no matter what their CD4 count. This recommendation also includes the following:

    • HIV treatment can prevent both AIDS-related and non-AIDS-related illness in people living with HIV
    • HIV treatment can prevent transmission of HIV to others. Research has shown that taking HIV drugs as they are prescribed can reduce the amount of HIV in the blood and genital fluids. Therefore, people living with HIV and taking HIV treatment are less likely to spread the virus to others.
    • HIV treatment should only be started when people understand the risks and benefits of treatment and are willing and able to commit to taking HIV drugs as they are prescribed (this is known as adherence)
  • HIV treatment is also strongly recommended if you are in one or more of the following situations, no matter what your CD4 count:

    • You have or had symptoms of AIDS (such as opportunistic infections, also called OIs)
    • You are a pregnant woman
    • You have HIV-related kidney disease (HIVAN or HIV nephropathy)
    • You need treatment for hepatitis B and/or hepatitis C
  • HIV drugs should be offered to people who are at risk of spreading HIV to their sexual partners. This is referred to as Treatment as Prevention (TasP).

Because starting medication is such an important decision, the guidelines suggest considering more than just your CD4 count and viral load. It is important to think about whether you are ready to start and able to take your medications as prescribed. You and your health care provider should consider the risks and benefits of starting treatment earlier or later.

Benefits of Starting Early

  • Having a higher CD4 cell count and keeping it high
  • Preventing further damage to the immune system
  • Decreasing risk for HIV-related and non-HIV-related health problems
  • Reducing your risk of spreading HIV to others (also known as Treatment as Prevention), including sexual partners and babies (through perinatal transmission, or mother-to-child transmission)

Risks of Starting Late

  • Having a severely weakened immune system. This can mean that it takes longer to restore your immune system to full strength and you to full health. Recent studies have shown that delaying treatment can increase the chances that people living with HIV will develop AIDS and other serious illnesses.
  • Having an increased chance of immune reconstitution syndrome when you begin taking HIV drugs
  • Spreading HIV to others, including sexual partners and babies (if you become pregnant)
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This article was provided by The Well Project. Visit The Well Project's Web site to learn more about their resources and initiatives for women living with HIV. The Well Project shares its content with TheBody.com to ensure all people have access to the highest quality treatment information available. The Well Project receives no advertising revenue from TheBody.com or the advertisers on this site. No advertiser on this site has any editorial input into The Well Project's content.
 

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