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Massive Change in U.S. Treatment Guidelines

January 2010

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Considering Delaying the Start of Therapy

Rushing the initiation of therapy is rarely a good idea and the panel writes that "some patients and their clinicians may decide to defer therapy for a period of time based on clinical or personal circumstances." Although deferring therapy might be reasonable for patients with high CD4+ cell counts, the panel states that "deferral for patients with much lower CD4+ counts (less than 200 cells) should be considered only in rare situations and should only be undertaken with close clinical follow-up. A brief delay in initiating therapy may be considered to allow a patient more time to prepare for lifelong treatment."

Next are some issues that doctors and patients may encounter that might affect the decision to initiate or delay therapy.


Adherence

A high level of adherence to HIV treatment is vital to minimize the risk of developing drug resistance and reducing future treatment options. The panel notes that in cases where patients may be at risk of poor adherence, it may be "prudent" to defer treatment while the barriers to adherence are being addressed. However, in cases where the initiation of anti-HIV therapy is considered urgent, physicians may override their concerns about adherence. When might therapy be needed urgently? See "Other conditions" listed toward the end of section B in this newsletter.


Severe Co-Existing Health Issues

The guidelines state that delaying the initiation of anti-HIV therapy may be considered when "either the treatment or manifestations of other medical conditions could complicate the treatment of HIV infection or vice versa." The panel provides these examples to highlight this point:

  • the need for surgery that could result in a significantly prolonged interruption of therapy
  • taking medicines that have clinically significant drug interactions with anti-HIV therapy

The panel assumes that both of the conditions or situations mentioned above are temporary and that anti-HIV therapy will swiftly begin after these problems have been resolved.

There are certain rare situations in which physicians may choose to not prescribe anti-HIV therapy. Usually these are cases where patients have other conditions that considerably shorten their life span or cause very poor quality of life, such as these:

  • the presence of incurable cancers unrelated to HIV infection
  • the final stage of liver disease where extremely ill health precludes transplantation


Elite Controllers

Researchers have coined the term "elite controllers" to describe an unusual group of HIV-positive people (less than 1%) who can have suppressed viral loads and high CD4+ cell counts for many years without using treatment. It is possible that elite controllers may somehow benefit from the early use of anti-HIV therapy. However, there is no data to support such an idea. So the panel did not recommend treatment for this group of people.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication TreatmentUpdate. Visit CATIE's Web site to find out more about their activities, publications and services.
 
See Also
Read the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
More News and Analysis on HIV Treatment Guidelines


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