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The updated European and US guidelines for the treatment of HIV are now available. The European AIDS Clinical Society (EACS) produced the European Guidelines for treatment of HIV infected adults in Europe. Version 5 of this document was published in November 2009.1
Recently AIDSinfo announced the release of the updated US Department of Health and Human Services (DHHS) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents.2 The following key changes were made to the November 2008 version of the US guidelines.
1. New section titled "Considerations in Managing Patients with HIV-2 Infection"
This section briefly reviews the current knowledge on the epidemiology and diagnosis of HIV-2 infection and the role of antiretroviral therapy in the management of patients with HIV-2 mono-infection and HIV-1/HIV-2 co-infection.
2. Drug Resistance Testing More specific recommendations are given on when to use genotypic versus phenotypic testing to guide therapy in treatment-experienced patients with viraemia while on treatment.
Genotypic testing is recommended as the preferred resistance testing to guide therapy in patients with suboptimal virological responses or virological failure while on first or second regimens (AIII).
Addition of phenotypic testing to genotypic testing is generally preferred for persons with known or suspected complex drug resistance mutation patterns, particularly to protease inhibitors (BIII).
3. Initiation of Antiretroviral Therapy The Panel recommends earlier initiation of antiretroviral therapy with the following specific recommendations:
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Antiretroviral therapy should be initiated in all patients with a history of an AIDS-defining illness or with CD4 cell count < 350 cells/mm3 (AI).
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Antiretroviral therapy should also be initiated, regardless of CD4 cell count, in patients with the following conditions: pregnancy (AI), HIV-associated nephropathy (AII), and hepatitis B virus (HBV) co-infection when treatment of HBV is indicated (AIII).
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Antiretroviral therapy is recommended for patients with CD4 cell counts between 350 and 500 cells/mm3. The Panel was divided on the strength of this recommendation: 55% of Panel members for strong recommendation (A) and 45% for moderate recommendation (B) (A/B-II).
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For patients with CD4 cell counts >500 cells/mm3, 50% of Panel members favor starting antiretroviral therapy (B); the other 50% of members view treatment as optional (C) in this setting (B/C-III).
Patients initiating antiretroviral therapy should understand the benefits and risks of therapy and the importance of adherence (AIII).
Patients may choose to postpone therapy, and providers may elect to defer therapy, based on clinical and/or psychosocial factors on a case-by-case basis.
4. What to Start in Antiretroviral-Naïve Patients Regimens recommended in treatment-naïve patients have been defined and classified as:
The following regimen changes were made in the recommendations:
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Raltegravir + tenofovir/emtricitabine has been added as a Preferred regimen based on the results of a Phase III randomized controlled trial (AI).
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Four regimens are now listed as ?Preferred? regimens for treatment-naïve patients. They are:
- efavirenz/tenofovir/emtricitabine;
- ritonavir-boosted atazanavir + tenofovir/emtricitabine;
- ritonavir-boosted darunavir + tenofovir/emtricitabine; and
- raltegravir + tenofovir/emtricitabine
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Lopinavir/ritonavir-based regimens are now listed as ?Alternative? (BI) instead of ?Preferred? regimens, except in pregnant women, where twice-daily lopinavir/ritonavir + zidovudine/lamivudine remains a ?Preferred? regimen (AI).
5. Other sections and tables updates include:
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What Not to Use
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Management of Treatment-Experienced Patients
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Treatment Simplification
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Hepatitis C Co-infection
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Antiretroviral-Associated Adverse Effects
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Antiretroviral Drug Interactions
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Preventing Secondary Transmission of HIV
The Australian ARV Guidelines Panel held a teleconference on 08/12/09. An additional face-to-face meeting will be held late January 2010 to discuss the recommendations from the DHHS Guidelines. The updated Australian commentary will be available by April 2010 on the ASHM website.
2.Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. December 1, 2009;1-161. Available at http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf( cited December, 2009)
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