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New Guidelines for Treatment of HIV Infection in Adults

Experts update 2012 recommendations

A panel of international experts in human immunodeficiency virus (HIV) research and patient care has provided updated treatment recommendations for adults with HIV, emphasizing when to start treatment; what treatment to start; the use of laboratory monitoring tools; and managing treatment failure, switches, and simplification.

The new guidelines were published online prior to being printed in the July 23/30 issue of JAMA.

The authors considered previous data and reviewed new data since a 2012 guideline update, with literature searches in PubMed and EMBASE through June 2014.

The panel recommends antiretroviral therapy (ART) for all adults with HIV infection and for the prevention of HIV transmission. ART is recommended regardless of the CD4 cell count, and treatment should be started as soon as possible, preferably within the first 2 weeks of diagnosis, in patients with opportunistic infections and other opportunistic diseases that define the illness, including all lymphomas and human papillomavirus-related cancers. In particular, ART is recommended for all HIV-infected persons with tuberculosis (TB) and should be started within 2 weeks of TB treatment when the CD4 cell count is less than 50/uL and by 8 to 12 weeks for those with higher CD4 counts.

Recommended initial treatment regimens include two nucleoside reverse transcriptase inhibitors (NRTIs) — abacavir/lamivudine or tenofovir disoproxil fumarate/emtricitabine — and a third single or boosted drug, which should be an integrase strand transfer inhibitor (ISTI), such as dolutegravir, elvitegravir, or raltegravir; a non-nucleoside reverse transcriptase inhibitor (NRTI), such as efavirenz or rilpivirine; or a boosted protease inhibitor, such as darunavir or atazanavir, according to the guidelines.

Alternative regimens are available. Boosted protease inhibitor monotherapy is generally not recommended, but NRTI-sparing approaches may be considered.

According to the authors, HIV-1 RNA levels should be monitored at about 4 weeks after treatment is initiated or changed, and then every 3 months to confirm the suppression of viremia below the limit of quantification of sensitive commercial assays. The CD4 cell count should be monitored at least every 3 months after the initiation of therapy, especially among patients with cell counts of less than 200/uL to determine the need for the initiation or discontinuation of primary opportunistic infection prophylaxis.

Once the HIV-1 RNA level has been suppressed for 1 year and the CD4 cell count is stable at greater than or equal to 350/uL, the viral load and the CD4 cell count can be monitored at intervals of 6 months or less in patients with dependable treatment adherence. Once the viral load has been suppressed for 2 years and the CD4 cell count is persistently greater than 500/uL, monitoring CD4 cell counts is optional unless virologic failure occurs or there are intercurrent immunosuppressive treatments or conditions.

Source: JAMA; July 21, 2014.

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