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U.S. Antiretroviral Therapy Guidelines

July 5, 2014

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Why Do the Guidelines Keep Changing?

We keep learning more about the best way to fight HIV. In 1998, the US Department of Health and Human Services created a panel of physicians, researchers, and consumers to develop treatment guidelines. They constantly review AIDS research results. The guidelines are updated about once each year. The panel released the latest guidelines in May 2014.

Note: These are guidelines, not rules. Patients should receive individualized care from a health care provider with experience treating HIV infection. The full text of these guidelines is available on the Internet at; choose "Guidelines."

Viral Load and CD4 Cell Testing

Viral load and CD4 cell tests provide critical information for decisions on antiretroviral therapy (ART). Before changing treatment, the tests should be repeated to confirm the results. Fact Sheet 124 has more information on CD4 cell tests and Fact Sheet 125 covers viral load testing.

Viral load should be tested:

  • Before starting or changing medications. This provides a reference value;
  • About 2 to 8 weeks after starting or changing medications. This shows whether the new drugs are working;
  • Every 3 or 4 months for 2 years, then every 6 months. This helps make sure the medications are still working. For patients who haven't started taking medications, it helps decide when to start.
  • Virologic failure is defined as a confirmed viral load over 200 copies.

CD4 cell counts should be done:

  • When someone first tests HIV-positive
  • Every 6 months to monitor the strength of the immune system
  • Optional if the viral load is under control.

Resistance Testing

Viral resistance testing helps health care providers choose the most effective drugs. See Fact Sheet 126 for more information. Resistance testing is recommended for patients starting therapy, when viral load is not controlled by new medications, or when it "breaks through" a regimen that used to work. The guidelines recommend resistance testing before starting antiretroviral treatment (ART). It can also make sense for people who don't need to start ART yet. This can show if the person got infected with drug-resistant virus.

Other Laboratory Tests

The guidelines recommend using a viral tropism test (see Fact Sheet 129) before starting therapy with a CCR5 inhibitor. They also suggest using a genetic test, HLA-B*5701 before starting abacavir (see Fact Sheet 416).

When to Start Treatment

  • Treatment is recommended for all HIV-infected individuals. Treatment is more necessary at lower levels of CD4 cells.
  • Regardless of CD4 count, treatment is recommended for all pregnant patients, and patients with HIV-associated nephropathy (a kidney disorder) or those who need treatment for hepatitis B.
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Read the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (PDF)
More on HIV Treatment Guidelines for Adults & Adolescents

This article was provided by AIDS InfoNet. Visit AIDS InfoNet's website to find out more about their activities and publications.