HIV Treatment Guidelines

Table of Contents

• Key Changes in the Revised March 2012 Guidelines
• What Are the Treatment Guidelines?
• Treatment Goals
• When to Start Treatment?
• What to Start With?
• Resistance Testing
• Taking Care of Yourself

Key Changes in the Revised March 2012 Guidelines

Some of the important updates in the most recent version of the Department of Health and Human Service's (DHHS) guidelines for the treatment of HIV in adults and adolescents are listed here:

• The DHHS's panel of experts now recommends that all people living with HIV (HIV+) take HIV drugs, no matter what their CD4 count
• In the HIV and Women section, there are new recommendations for HIV+ women who want to get pregnant with an HIV-negative male partner. The DHHS also notes that there are potential drug interactions between birth control pills (oral contraceptives) and two classes of HIV drugs -- protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). Additional or alternative methods to prevent pregnancy may be necessary.
• HIV/Hepatitis C coinfection: information on two newly approved hepatitis C drugs, including recommendations on giving these new drugs with HIV drugs
• HIV/Tuberculosis coinfection: new recommendations about when to start HIV drugs in people with tuberculosis who have not taken HIV drugs before
• Drug interactions: new tables listing interactions between HIV drugs and other medications commonly taken by those living with HIV (tables 14-16b)
• There are also two new sections: HIV and the Older Patient, and a table listing the costs of HIV drugs (Appendix C)

More information on updates to the treatment guidelines is included below.

What Are the Treatment 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 HIV+ people choose among the many available HIV drugs.

The 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 March 2012. The full version of the guidelines is available at http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf.

Some of the topics the guidelines cover are listed below.

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:

• Preserve or improve the health of your immune system by increasing your CD4 cells
• Get your viral load as low as possible for as long as possible
• Improve your quality of life and reduce illness and death
• Prevent HIV transmission

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 disease. 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 progressed. 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 guidelines state:

• HIV treatment is recommended for anyone who is HIV+, no matter what their CD4 count
• HIV treatment is also strongly recommended if you are in one or more of the following situations, no matter what your CD4 count:
  • You have or had symptoms of AIDS (such as opportunistic infections, also called OIs)
  • You are a pregnant woman
  • You have HIV-related kidney disease (HIVAN or HIV nephropathy)
  • You need treatment for hepatitis B (HBV)
• The DHHS panel's recommendation to begin treatment with a CD4 count above 500 is a "moderately strong" recommendation based on expert opinion and not on data from clinical trials. The panel's recommendation to begin treatment with a CD4 count under 500 is based on the results of well-designed studies.

[Note: Because the panel's expert opinion is not based on results from randomized controlled trials, which are often considered the 'gold standard' for providing evidence, there is some debate about the DHHS panel's new recommendation to begin treatment with a CD4 count above 500. In other words, while some experts agree that the current level and quality of evidence supports treatment above 500, other experts do not.]

• The guidelines also point to several conditions that increase the need for treatment, such as rapidly declining CD4 count (more than 100 cells per year) or higher viral load (more than 100,000 copies)
• HIV drugs should be offered to people who are at risk of spreading HIV to their sexual partners

Because starting medication is such an important decision, the guidelines suggest considering more than just your CD4 count and viral load. It is important to think about whether you are ready to start and able to take your medications as prescribed. You and your health care provider should consider the risks and benefits of starting treatment earlier or later.

Potential Benefits of Starting Therapy Early

• Keeping your CD4 count higher
• Lowering the risk of HIV-related problems that occur even when your CD4 count is high (such as tuberculosis and certain types of cancer)
• Lowering the risk of heart, liver, and kidney disease that occur more often in HIV+ people
• Reducing your risk of transmitting HIV to others

Potential Risks of Starting Therapy Early

• Experiencing drug-related side effects, including possible long-term side effects not yet known
• Developing drug resistance (when an HIV drug is no longer able to fight HIV effectively, we say that HIV has become "resistant" to that drug); drug resistance can reduce future treatment options