• When to Start ARV Therapy: Where Are We Now? (TuOrB148)
  Authored by Patrick Yeni
  Non-abstract driven session

Patrick Yeni from France gave us a one-day advance about the new antiretroviral guidelines from the International AIDS Society-USA that will be published in the July 10 issue of JAMA. This group has been publishing guidelines for the treatment of HIV for the last few years, and they always publish them in JAMA. This group should not be confused with the International AIDS Society -- the group that organizes the International AIDS Conference, like the one we just had in Barcelona -- which is led by Stephano Vella. In fact there are some tensions between those two groups (although many people belong to both), but that is a discussion/gossip for another day.

The main changes in the new recommendations are that CD4+ becomes almost the sole criteria to start antiretroviral therapy. Viral load is important in monitoring the response to therapy. These guidelines do not state that therapy should be started when CD4+ reaches 350 cells per mm³ as other guidelines do, and leave a gray area between 200 and 350 CD4+ cells where several other factors should be considered, including specific CD4+ cell count or decline rate, the viral load level, the patient's commitment to adhere to therapy, and the risk of side effects.

Regarding initial regimens, these guidelines do not commit, and try to be "political" by stating that boosted PIs and NNRTI-based regimens are pretty much equivalent. Many clinicians would question this recommendation, and several presentations at this meeting suggest that NNRTI-based regimens are the best initial option.

Both viral load and CD4+ cell counts are important at the time of monitoring therapy, not big news in this regard but the role of therapeutic drug monitoring is still unclear. Changing antiretroviral therapy in the presence of virologic failure should be individualized and optimized to increase the probability of success using resistance testing, again not big news in this area. During the conference in Barcelona, lots of new data about drugs like T-20 or tenofovir was available. These drugs will be important parts of our armamentarium to treat patients with multi-drug resistance.

If you are interested in reading the complete set of guidelines, you can check them out in the July 10 JAMA issue (access to full guidelines requires paid login).

Reference

1. Patrick G. Yeni, M.D.; Scott M. Hammer, M.D.; Charles C.J. Carpenter, et al. Antiretroviral Treatment for Adult HIV Infection in 2002. Updated Recommendations of the International AIDS Society-USA Panel. JAMA. 2002;288:222-235.