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HIV Treatment Guidelines

August 22, 2014

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. Links to all of these treatment guidelines can be found here. 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 May 2014. 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. The WHO recommends 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:

The guidelines also recommend using viral load tests instead of CD4 counts to see how HIV drugs are working.


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:


Key Changes in the Revised May 2014 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:

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. 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.

There is now more proof that untreated HIV is bad for your health at all stages of infection. Several large studies have shown that people who begin treatment early have a better outcome than those who wait to start treatment until their HIV has gotten worse. Also, the drug combinations now available are easier to take and have fewer side effects than older regimens. For these reasons the newest guidelines recommend starting earlier.

The current US guidelines state:

Potential Benefits of Starting Therapy Early

Potential Risks of Starting Therapy Early


What to Start With?

Once you have decided to start treatment, you and your health care provider need to choose what combination of drugs you are going to take. No HIV drug should ever be used by itself. There are many drugs to choose from. The HIV drugs work in different ways to stop the virus at different points in its lifecycle. The drugs are divided into classes as follows:

Your first treatment regimen will probably contain:

These combinations will attack HIV at different parts of its lifecycle to pack a strong punch against the virus.

In the US, the DHHS guidelines rank specific drug combinations as recommended or alternative (see below). While the recommended regimens are the best choices for HIV treatment, they may not be ideal for everyone. Because everyone's situation is different, there may be cases in which alternative treatments are actually better for you. You and your health care provider should choose drugs based on your specific needs. Think about what will fit into your lifestyle, including dose schedule, number of pills, and side effects. Also consider what other medications you are taking, any other medical conditions you have, and the results of resistance testing (see below).

Whatever regimen you choose to take, you need to take your drugs on schedule. This is called adherence. In order to get the most benefit from HIV treatment, good adherence is required. This is because HIV drugs need to be kept at a certain level in your body to fight the virus. If the drug level falls, HIV may have a chance to fight back and develop resistance. Skipping doses, not taking the drugs on time, or not following food requirements can cause your drugs to be less effective or stop working altogether.

For more information on the different classes of HIV drugs and how they work, see The Well Project's article HIV Drugs and the HIV Lifecycle. For more information on individual drugs sorted by class see The Well Project's HIV Drug Chart. Please note: for the regimens listed below, the brand name of an HIV drug is listed first and capitalized, with the generic name lower-cased and in parentheses. For example: Truvada (emtricitabine + tenofovir).

US DHHS Recommended Regimens

Study results of these combinations showed they were powerful and long-lasting, did not have a lot of side effects, and were easy to use. Recommended regimens include:

For people who have never taken HIV drugs before ("treatment naive"), regardless of baseline viral load or CD4 count:

For people with pre-treatment viral loads < 100,000 copies/mL, the following regimens are also recommended:

WHO Recommended Regimens

The WHO guidelines suggest that first-line HIV therapy be a combination of an NNRTI plus 2 NRTIs. Specifically, they recommend either: (1) Atripla (efavirenz + tenofovir + emtricitabine) or (2) Sustiva (efavirenz ) + Viread (tenofovir) + Epivir (lamivudine). These two regimens are also those recommended for women who are pregnant or breastfeeding.

US DHHS Alternative Regimens

These combinations have been proven effective and tolerable in clinical trials, but may have disadvantages compared to recommended regimens. Alternative regimens include:


Changing or Stopping Treatment

After starting HIV treatment, you may need to make some changes in your regimen. The DHHS panel of experts suggests that the primary focus when changing or switching drug regimens should be the maintenance of viral suppression without reducing future treatment options.

Reasons for switching or changing your HIV drug regimen include:


Resistance Testing

Drug resistance tests can tell if your virus is resistant to any HIV medications. This will help you and your health care provider choose the most effective drugs for you to take. The following are the US DHHS guidelines' recommendations on when to have a drug resistance test:


Taking Care of Yourself

There is much more information in the guidelines, including other possible drug regimens, what drugs not to take, and what types of resistance tests to use. There is also a lot of information on other aspects of HIV care and treatment, including adherence, drug side effects and interactions, special considerations for people with liver or kidney problems, salvage therapy (treatment for people who have used and are resistant to many HIV drugs), and treatment when you have HIV and either tuberculosis, hepatitis B, or hepatitis C. For HIV+ women, the guidelines contain important information on pregnancy and women-specific treatment issues.

The guidelines are a set of recommendations to help you and your health care provider understand your treatment choices. They are based on the most up-to-date information from studies and clinical trials. But, remember, they are only general suggestions. It is okay for you to choose therapies for your specific situation. Use the guidelines as a resource to help you make well-informed treatment decisions that are right for you.




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