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HIV Treatment Guidelines: Adults and Adolescents

By Liz Highleyman

Summer/Fall 2010

U.S. and global experts continue to issue updated guidelines for HIV treatment to reflect the latest study findings.

Coinciding with AIDS 2010, the International AIDS Society-USA (IAS-USA) released new antiretroviral treatment guidelines for adults, updating the previous version from 2008. Published in the July 21, 2010, Journal of the American Medical Association, these recommendations concur with those of the U.S. Department of Health and Human Services (DHHS), which advise that asymptomatic HIV positive people should initiate ART when their CD4 T-cell count falls to 500 cells/mm3, with no upper limit.

Like the DHHS, the IAS-USA panel recommended starting with two NRTIs, preferably the fixed-dose tenofovir/emtricitabine pill (Truvada), along with either a ritonavir-boosted protease inhibitor, the NNRTI efavirenz (Sustiva), or the integrase inhibitor raltegravir (Isentress).

Once started, ART should not be interrupted except in the context of a clinical trial. People who experience virological failure should, if possible, switch to a regimen that includes at least two, and ideally three, fully active drugs in order to avoid resistance. Boosted protease inhibitor monotherapy should be avoided, the panel said.

The IAS-USA panel also recommended treatment for some groups regardless of CD4 cell count, including pregnant women, people older than 60 years, and people with coexisting conditions such as hepatitis B or C, HIV-associated kidney disease, or elevated cardiovascular risk. But the panel emphasized the importance of assessing individual readiness before starting therapy.

The panel weighed in on the ongoing debate about when to start treatment, noting that early ART may help control systemic inflammation and reduce the risk of HIV transmission (see "HIV Treatment Guidelines: Pregnant Women and Babies," in this issue). "The prominence of non-AIDS events as a major cause of morbidity and mortality in those with ongoing HIV replication suggests that early ART initiation may further improve the quality and length of life for persons living with HIV," the panel members wrote. The full IAS-USA recommendations are available online at the Journal of the American Medical Association.

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




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