Start ART in all HIV-infected adults, expert panel says

All adults with HIV should receive antiretroviral therapy (ART) regardless of CD4 cell count, according to the 2012 International Antiviral Society-USA panel recommendations.

Experts updated the previous 2010 guidelines based on observational cohort data finding all HIV-positive patients may benefit from ART and data from a randomized controlled trial showing that ART reduces the likelihood of spreading HIV. The findings were presented at the International AIDS Conference in Washington, D.C., on Sunday and appear in the July 25 Journal of the American Medical Association.

There is no CD4 cell count threshold at which starting therapy is contraindicated, but the strength of the recommendation and the quality of the evidence supporting therapy increase as the CD4 cell count decreases and in patients who are pregnant, have hepatitis B or C, are older than 60 years, or have HIV-associated nephropathy. Ongoing monitoring of patients' CD4 cell count, HIV-1 RNA levels, ART adherence, HIV-drug resistance, and quality-of-care indicators is recommended.

Because any drug regimen to treat HIV is lifelong, therapy choices should consider patient convenience and tolerability. Recommended initial therapy is still a combination of two nucleoside reverse transcriptase inhibitors and a potent third agent (generally a nonnucleoside reverse transcriptase inhibitor, a ritonavir-boosted protease inhibitor, an integrase strand transfer inhibitor, or, rarely, an agent that blocks the CC chemokine receptor 5).

In the same issue of JAMA, in a study evaluating screening for cervical disease in women with HIV, researchers reported that HIV-infected and uninfected women with a normal Pap test and a negative test result for oncogenic human papillomavirus (HPV) DNA at study enrollment had a similar risk of cervical precancer and cancer after five years of follow-up. Additional observational studies or a randomized clinical trial may be necessary before clinical guideline committees consider whether to expand current recommendations regarding HPV co-testing to HIV-infected women, according to the study authors.

“More broadly, the current investigation highlights the potential for a new era of molecular testing, including HPV as well as other biomarkers, to improve cervical cancer screening in HIV-infected women,” the authors wrote.