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Revised U.S. HIV Treatment Guidelines Include Minor Changes, Reassurance on Viral Load "Blips"

By Myles Helfand

January 10, 2011

In recent years, we in the HIV information world in the U.S. have taken to holding our breaths whenever a new version of the official U.S. HIV treatment guidelines is released. The last time the guidelines were updated, in December 2009, they altered some of the basic rules that health care professionals should follow regarding when a person should start HIV treatment and what HIV meds he or she should take.

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No such earth-shattering changes this time around. New guidelines were released this morning, and they include no major changes to "when to start" treatment or "what to start with." However, they do include a number of minor, but noteworthy, changes that could impact some aspects of HIVers' health care.

Officially called the U.S. Department of Health and Human Services' Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (and often referred to in shorthand as "the DHHS guidelines"), this document is widely regarded as a bible of sorts for HIV health care providers. It's updated about once a year by a panel of some of the country's top HIV/AIDS doctors, researchers and community members.

This time around, the DHHS guidelines update focused more on subtle tweaks than big, game-changing adjustments. They include:

  • Fewer CD4 tests. A person on HIV treatment typically gets an updated CD4 count every three to six months. The updated guidelines suggest that, if a person's CD4 count is "well above the threshold for opportunistic infection risk" (in other words, well over 200), he or she can safely get a new CD4 count every six to 12 months instead -- which could translate to fewer blood tests and reduced expense. (The guidelines noted, though, that more frequent CD4 testing is warranted if a person develops any HIV-related symptoms or begins taking non-HIV medications that can alter his or her CD4 count, such as interferon for hepatitis C.)
  • "Blips" don't matter. Many HIVers will occasionally see their viral load jump slightly above undetectable from time to time, which is commonly referred to as a "blip." The guidelines now say that a blip or two is not worth worrying about, provided none of the blips go above 200.
  • "When" and "with what" unchanged. No changes were made to the list of "preferred" first-line HIV treatment regimens. However, thanks to the approval of Selzentry (maraviroc, Celsentri) as a first-line drug last year, a regimen of Selzentry and Combivir (AZT/3TC) has now been added to the "acceptable" list, which is a couple of notches below "preferred." The guidelines also note that two other Selzentry-based regimens -- in which the drug is paired with either Truvada (tenofovir/FTC) or Epzicom (abacavir/3TC, Kivexa) -- may be OK, but haven't been studied enough yet for us to be sure.
  • Invirase demoted. Regimens that include Invirase (saquinavir) boosted with Norvir (ritonavir) are no longer considered "alternative" (one notch below "preferred"), because of recent findings that the Invirase can potentially mess with a person's heart rhythm. They're now listed as regimens that "may be acceptable but should be used with caution."
  • Stepping up HAART for people with tuberculosis. More aggressive HIV treatment is now recommended for people who have both tuberculosis and HIV, but who haven't yet started taking HIV meds. In the past, the guidelines have been unclear on how quickly to start HIV treatment in people who are being treated for tuberculosis, especially if they have a low CD4 count. But recent research in this area has cleared up the picture somewhat. The guidelines panel now recommends starting HIV meds within two to four weeks after starting tuberculosis treatment if a person's CD4 count is 500 or lower, and within eight weeks of tuberculosis treatment if it's above 500.
  • Hepatitis B treatment guidelines refined. Each edition of the guidelines tends to provide more specific guidance when it comes to treating coinfections. The recommendations for hepatitis B treatment now include new info on dealing with resistance to Emtriva (emtricitabine, FTC) and Epivir (lamivudine, 3TC), as well as what to do if a person can't take Viread (tenofovir) due to side effects.

A more complete rundown of the changes to these guidelines is available on our site (courtesy of the DHHS), as is a PDF of the entire, 166-page guidelines document.

Myles Helfand is the editorial director of TheBody.com and TheBodyPRO.com.

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Copyright © 2011 The HealthCentral Network, Inc. All rights reserved.

See Also
Read the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (PDF)
More News and Analysis on HIV Treatment Guidelines

Reader Comments:

Comment by: solly K (Minneapolis) Thu., Jan. 27, 2011 at 12:20 pm EST
So instead of getting a CD4 count every 3 months???? I'm not on treatment I get a cd4 count every 3 months. Do these guidelines apply to me. Instead you should get tested every 6 months or 1 year? If you're going to write something like this, can you write so that everyone understands?
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Replies to this comment:
Comment by: Myles Helfand (TheBody.com) Mon., Jan. 31, 2011 at 11:40 am EST
Hey Solly -- the CD4 count thing pertains specifically to people who are on HIV meds. If you feel your CD4 count is high enough (and stable enough) that you can get tested less often, that's something you should discuss with your doctor, so the two of you can work through the pros and cons of less-frequent testing.


Comment by: Linda (Boise Idaho) Tue., Jan. 25, 2011 at 11:41 am EST
Truvada has not been studied enough to be sure if its ok? Would you mind explaining that in a bit more detail as it is one of the medications
my sons on .
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Replies to this comment:
Comment by: Myles Helfand (TheBody.com) Tue., Jan. 25, 2011 at 3:01 pm EST
Sure, Linda -- I failed to realize how that choice of phrasing on my part ("may be OK, but haven't been studied enough yet for us to be sure") could potentially increase some stress levels among people who are taking one of those regimens, and I apologize for that.

Selzentry was approved by the FDA for use as a first-line medication based on the results of a study known as A4001026 (the name just rolls off the tongue), which compares twice-daily Selzentry + Combivir to Sustiva + Combivir. After about two years of study, the Selzentry/Combivir regimen did well, and it's based on those results that it got the nod as an "acceptable" first-line regimen.

We haven't yet seen similar studies (of similar length) done for Selzentry + Truvada or Selzentry + Epzicom, so the guidelines panel didn't feel comfortable saying that those regimens were definitely fine. This does not mean that those regimens are definitely unsafe or that they won't keep at HIV at bay; it's just that the research on them hasn't reached a point where the guidelines panel felt comfortable adding them to their official list of recommended, acceptable and alternative regimens.

I'd definitely encourage you to chat with your son's doc if you have concerns about his regimen. I'm a journalist, not a medical professional, so I can't remotely provide you with medical advice -- all I can do is relay the facts as I understand them. Our own online docs in our "Ask the Experts" forums might also be able to explain things further for you if you post a question there.


Comment by: beth (nyc) Sun., Jan. 23, 2011 at 9:08 am EST
no meds, no VL for 25 years. HIV positive but no VL - it was registered 77, Am I a denialist?
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Replies to this comment:
Comment by: Myles Helfand (TheBody.com) Tue., Jan. 25, 2011 at 3:03 pm EST
It sounds like you might be a "long-term nonprogressor" or an "elite controller," Beth. Hop over to http://www.thebody.com/index/treat/nonprog.html if you'd like to learn more, and please consider joining a study!


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