AIDS society updates antiretroviral recommendations for U.S. adults
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New data about untreated HIV and expanded treatment options led a panel to update recommendations for antiretroviral therapy (ART) in U.S. adults.
The International AIDS Society-USA guidelines recommend when to start ART, what type to choose, how to monitor and when to change therapies. Recommendations appear in the July 21 Journal of the American Medical Association.
Patients must be ready to undertake lifelong ART, the guidelines said. Therapy is recommended for symptomatic patients regardless of CD4 cell count, and for asymptomatic individuals with CD4 cell counts <500/µL. Risk reduction counseling should be done at each patient-clinician interaction.
When selecting a regimen, clinicians should consider resistance-testing results and predicted virologic efficacy, toxicity and tolerability, pill burden, dosing frequency, drug-drug interactions, comorbidities, patient and practitioner preference, and cost and affordability. Current evidence supports combining two nucleoside reverse transcriptase inhibitors and a potent third agent from another class. Fixed-dose formulations and once-daily regimens are preferred.
Effective therapy should suppress HIV to less than 50 copies/mL (polymerase chain reaction) or 75 copies/µL (branched DNA) by 24 weeks. To detect failure, testing of HIV-1 RNA should be repeated two to eight weeks after initiation, every four to eight weeks until suppressed, and then every three to four months for at least the first year. CD4 cell counts should be monitored at least every three to four months after starting therapy, especially in patients with counts <200/µL, to assess whether prophylaxis is needed for opportunistic infections. Patients who have changed therapy because of virologic failure need more frequent monitoring. Even if one or more regimens have failed, the therapeutic goal should still be undetectable plasma HIV-1 RNA levels. This goal is achievable with new drugs and regimens, the guidelines said.
If an elevation in viral load occurs after complete suppression is achieved, physicians should consider poor adherence, drug-drug interactions, concurrent infections and recent vaccinations as possible causes before changing regimens. Testing for an isolated detectable viral load should be repeated to exclude errors or self-resolving low-level viremia.
When changing regimens after first- or multiple-regimen failure, physicians should consider the stage of HIV, nadir and current CD4 cell count, comorbidities, treatment history, current and previous drug resistance tests, and drug interactions. At least two drugs, and preferably three fully active drugs, should be included and drugs from new classes should be considered.
Single-agent switches to decrease toxicity, avoid drug interactions, or improve convenience and adherence are possible, provided the potency of the regimen is maintained and drug interactions are managed. Boosted protease inhibitor monotherapy is not recommended, except when other drugs raise issues of toxicity or tolerability. Delaying such switches may affect adherence and risk development of resistance.