The U.S. Department of Health & Human Services announced an update to the federal Guidelines for treating HIV on January 10, 2011. The revisions are mostly small changes to using certain HIV meds, CD4 counts and viral load test results. Other changes include treating people co-infected with hepatitis B or tuberculosis.
The Guidelines describe several groups of regimens when starting HIV treatment: "preferred," "alternative," "acceptable/may be acceptable" and "may be acceptable but used with caution." The first group includes regimens that generally are more tolerable and the most potent. Each group after begin to have increasingly more disadvantages than the one before it. The new recommendations highlight three changes in first line treatment:
A small change was made in recommending how often CD4 counts are done. The new recommendation is that the CD4 count may be monitored less often, for example every 6-12 months (instead of every 3-6 months). This applies to those who are on treatment and remain undetectable with no new changes in their general health, such as new HIV symptoms or having to start medicines that affect the immune system (interferon, corticosteroids, etc.)
Low-level results (typically <200) are commonly reported from some viral load tests. These results tend to be caused more by isolated "blips" due to the test's variability rather than being an actual increase in viral load. The new recommendation cautions providers not to use "detectable" viral load below 200 as a reason to switch treatment. Trends over time, such as a continually increasing viral load with two or more tests, are more accurate predictors of treatment success or failure.
HIV resistance is a concern for any HIV drug, including the newest class of integrase inhibitors. However, standard genotypic tests only check for mutations for the NRTIs and protease inhibitors. The new recommendations encourage providers to order genotypic tests specifically for integrase inhibitors in addition to other genotypic tests done.
All HIV-positive people with active TB should be treated with HIV treatment. For patients with <200 CD4s, HIV treatment should be started within 2-4 weeks of starting TB treatment. For patients with 200-500 CD4s, the Guidelines Panel recommends starting HIV treatment within 2-4 weeks, or at least within 8 weeks, after starting TB treatment. For patients with >500 CD4s, most Panel members also recommend starting HIV treatment within 8 weeks of TB treatment.
This section has been revised to provide recommendations for managing co-infected people, including those with HBV infection resistant to 3TC or FTC and for patients who cannot tolerate tenofovir (Viread).