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Information

HIV Treatment Guidelines

February 13, 2017

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Table of Contents


What Are Treatment Guidelines?

Treatment 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. They also help providers and people living with HIV (HIV+) choose among the many available HIV drugs.


U.S. Guidelines

A branch of the U.S. government, called the Department of Health and Human Services, (DHHS), has put together a set of HIV treatment guidelines. The U.S. DHHS provides several different treatment guidelines related to HIV care. These include the Perinatal Guidelines which provide treatment recommendations for pregnant women with HIV, the Treatment of Opportunistic Infections Guidelines which provide treatment recommendations for opportunistic infections, and the Pediatric Antiretroviral Treatment Guidelines. This fact sheet 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 July 2016. 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.


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Global Guidelines

In 2015, the World Health Organization (WHO) released new guidelines on when to start HIV treatment. By October 2015, all internationally-written guidelines were in agreement for the first time since 2006. The DHHS, WHO, EACS (European AIDS Clinical Society), BHIVA (British HIV Association), and the IAS-USA (International Antiviral Society-USA) now all recommend that HIV treatment be offered to 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.


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. These include:

  • 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 July 2016 U.S. 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:

  • New recommended treatment regimens in the "What to Start" section (see more below). These regimens contain tenofovir alafenamide fumarate (TAF). TAF is a close cousin of tenofovir disoproxil fumarate (TDF), which is the form of tenofovir known by the brand name Viread and found in other combination drugs such as Truvada. An advantage of TAF over TDF is it can be given at lower doses than TDF while achieving the same level of HIV suppression. It also appears to produce less bone loss and less reduction in kidney function than TDF.
  • These treatment recommendations apply to all people living with HIV, including all women living with HIV. It is especially important that pregnant women receive HIV treatment as early as possible during pregnancy and continue to take it after pregnancy.
  • Several new treatment recommendations for people co-infected with HIV and hepatitis C (HCV), hepatitis B (HBV), or tuberculosis (TB).

More information on what the guidelines recommend is included below.


When to Start Treatment?

Over the years there has been a lot of discussion and debate about when to start treatment, especially for people living with HIV with high CD4 counts -- those who have no signs of ill health and are relatively healthy. 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 this is not true.

The results of 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 both AIDS-related and non-AIDS-related illnesses.

The START trial clearly showed 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 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 U.S. 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 U.S. guidelines state:

  • HIV treatment is recommended for anyone who is living with HIV, regardless of 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).
  • While HIV treatment is recommended for all people living with HIV, it is especially urgent to start treatment if you:
    • have or had symptoms of AIDS (such as opportunistic infections, also called OIs)
    • are a pregnant woman
    • have HIV-related kidney disease (HIVAN or HIV nephropathy)
    • are co-infected with hepatitis B and/or hepatitis C
    • have a lower CD4 count (<200 cells/mm)
    • have acute/early infection
    • have HIV-related kidney disease (HIV-associated nephropathy, or HIVAN)
  • 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 research shows people with undetectable viral loads are very unlikely to transmit HIV to their sexual partners.

Because starting treatment is such an important decision, the guidelines suggest that you and your provider discuss the benefits of treatment while also addressing any barriers. It is important to think about whether you are willing and able to take your HIV treatment as prescribed. In order to get the most benefit from HIV drugs, they must be used just the way they are prescribed. Taking your treatment correctly is as important as which drugs you and your health care provider choose. So before you get started, it is important to be prepared and commit to taking your HIV drugs the right way, every day for your own health. For more information, see our fact sheet on Considerations Before Starting HIV Treatment.


Benefits of Starting Early

There are benefits to starting HIV treatment early. These include:

  • 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

There are also risks to starting HIV treatment late including:

  • Having a severely weakened immune system. This can mean 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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