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Federal Guidelines for the Use of Anti-HIV Therapy

December 2001

Article: Federal Guidelines for the Use of Anti-HIV Therapy

Advanced stage disease (severe symptoms of AIDS), with any CD4+ or viral load level.

All people with severe symptoms of AIDS are encouraged to be treated with anti-HIV therapy. In this case, therapy is shown to prolong life and improve symptoms. When starting therapy to prevent or treat serious infections (called opportunistic infections) at the same time as starting anti-HIV therapy, special care should be taken to avoid drug interactions. A person experiencing an opportunistic infection is generally encouraged to continue anti-HIV therapy.

No symptoms of HIV disease, with CD4+ cell counts below 200 and any viral load.

Anti-HIV therapy should be offered after considering the issues for making treatment decisions.

No symptoms of HIV disease, with CD4+ cell counts between 200-350 and any viral load.

Anti-HIV therapy should generally be offered, though controversy exists. Some experts believe it is often safe to wait until the CD4+ cell count falls to 200. Others believe this offers too little room to accommodate individual differences in how HIV disease progresses. In this case, they feel it's safer to start therapy at CD4+ cell counts of 350.

No symptoms of HIV disease, with CD4+ cell counts above 350 and viral load above 30,000 copies by bDNA or 55,000 by RT-PCR.

There are two unproven theories about treating early HIV infection in people without symptoms: aggressively vs. conservatively. For people who meet this definition, there are no data to suggest which approach results in longer survival. Very early, aggressive treatment might lead to longer life and greater preservation of the natural immune response against HIV. Or, it might lead to using up the limited supply of therapies too early in the course of the disease. As well, it risks early exposure to possible long-term side effects from therapies. As a result, many experts would delay starting therapy and continue to monitor CD4+ cell counts and viral load until certain levels are reached. On the other hand, the risk of disease progression over the next three years is somewhat high (over 30%) in people who meet this definition. As a result, other experts prefer to start treatment without further delay, believing that preventing damage by the virus may be preferable to trying to repair what breaks later on.

No symptoms of HIV disease, with CD4+ cell counts above 350 and viral load below 30,000 copies (bDNA) or 55,000 (RT-PCR).

Many experts would delay therapy and continue to monitor CD4+ cell counts and viral load. The risk of disease progression over the next three years in this group is low (below 15%).

Acute HIV infection (very early, typically within days to weeks after initial infection).

If infection is suspected, test for HIV using sensitive methods. (Note: technologies that measure viral load are not approved for diagnosing HIV infection and are discouraged for this use.) Experts agree that if treatment is offered this early, it should only be done in the context of a study. People interested in exploring very early treatment should be made aware of all its potential risks. The true long-term effect of early treatment is unknown because current studies are not yet complete. The hope, though, is that it might lead to a less aggressive course of disease. Whether or not this is the "right" approach remains unknown.


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