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New Guidelines Recommend Earlier Treatment

By Liz Highleyman

Winter/Spring 2010

On December 1, the U.S. Department of Health and Human Services (DHHS) released the latest version of Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Based on a growing body of evidence, treatment is now recommended for people with 350-500 cells/mm3; half the expert panel favored treatment even for people with more than 500 cells/mm3, while the remainder deemed it "optional."

The guidelines also recommend ART, regardless of CD4 count, for pregnant women, people with HIV-associated nephropathy (kidney disease), and hepatitis B virus (HBV) coinfection requiring treatment. In addition, the integrase inhibitor raltegravir (Isentress) was added to the list of "preferred" options for first-line therapy, while lopinavir/ritonavir (Kaletra) was changed to "alternative" due to side effects. The DHHS guidelines are available at www.aidsinfo.nih.gov/Guidelines/.

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The latest guidelines from the European AIDS Clinical Society, released in November, do not include a blanket recommendation for ART initiation under 500 cells/mm3, but do recommend treatment initiation within the 350-500 cells/mm3 range, or even higher, for pregnant women, people older than 50 years, individuals with high HIV viral load or rapidly declining CD4 count, and people with coexisting conditions, including hepatitis B or C, kidney disease, cancer, and elevated cardiovascular risk.

On the eve of World AIDS Day, the World Health Organization (WHO) issued updated global HIV treatment guidelines, which are widely used in low- and middle-income countries. The new WHO guidelines recommend ART initiation at 350 cells/mm3, up from 200 cells/mm3.

Based on recent studies, WHO also now recommends that HIV positive mothers and/or their infants should take antiretroviral drugs during breastfeeding, which the agency advises should continue throughout the first year of life. Finally, the guidelines recommend replacing more toxic drugs -- such as d4T (stavudine; Zerit) -- with more tolerable alternatives. The WHO guidelines are available at www.who.int/hiv/pub/arv/advice/en/index.html.

Liz Highleyman (liz@black-rose.com) is a freelance medical writer based in San Francisco.




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