Hammer SM, Eron JJ Jr, Reiss P, et al. Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society-USA panel

Division of Infectious Diseases, Columbia University College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 08/2008; 300(5):555-70. DOI: 10.1001/jama.300.5.555
Source: PubMed

ABSTRACT The availability of new antiretroviral drugs and formulations, including drugs in new classes, and recent data on treatment choices for antiretroviral-naive and -experienced patients warrant an update of the International AIDS Society-USA guidelines for the use of antiretroviral therapy in adult human immunodeficiency virus (HIV) infection.
To summarize new data in the field and to provide current recommendations for the antiretroviral management and laboratory monitoring of HIV infection. This report provides guidelines in key areas of antiretroviral management: when to initiate therapy, choice of initial regimens, patient monitoring, when to change therapy, and how best to approach treatment options, including optimal use of recently approved drugs (maraviroc, raltegravir, and etravirine) in treatment-experienced patients.
A 14-member panel with expertise in HIV research and clinical care was appointed. Data published or presented at selected scientific conferences since the last panel report (August 2006) through June 2008 were identified.
Data that changed the previous guidelines were reviewed by the panel (according to section). Guidelines were drafted by section writing committees and were then reviewed and edited by the entire panel. Recommendations were made by panel consensus.
New data and considerations support initiating therapy before CD4 cell count declines to less than 350/microL. In patients with 350 CD4 cells/microL or more, the decision to begin therapy should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient readiness for treatment. In addition to the prior recommendation that a high plasma viral load (eg, >100,000 copies/mL) and rapidly declining CD4 cell count (>100/microL per year) should prompt treatment initiation, active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy increasingly prompt earlier therapy. The initial regimen must be individualized, particularly in the presence of comorbid conditions, but usually will include efavirenz or a ritonavir-boosted protease inhibitor plus 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine). Treatment failure should be identified and managed promptly, with the goal of therapy, even in heavily pretreated patients, being an HIV-1 RNA level below assay detection limits.

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Available from: Robert Schooley, Aug 26, 2015
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    • "Self-management is comprised of modifiable daily tasks that individuals do to manage their chronic illnesses (Bodenheimer, Lorig, Holman, & Grumbach, 2002; Lorig & Holman, 2003; Richard & Shea, 2011). The development and widespread availability of HIV antiretroviral therapy has transformed HIV into one such chronic illness, requiring continual self-management work, generally outside of the health care system (Ford, Calmy, & Mills, 2011; Hammer et al., 2008). For HIV, self-management is a set of behaviors that directly and indirectly decrease susceptibility to worsening HIV. "
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    • "Efavirenz ((4S)-6-chloro-4-(2-cyclopropylethynyl)-4-(trifluoromethyl)- 2,4-dihydro-1H-3,1-benzoxazin-2-one; trade names: Sustiva, Stocrin) is one of the recommended NNRTIs and, because of its superior virologic efficacy, it remains the antiretroviral drug of choice (Arribas, 2003; Best and Goicoechea, 2008; Sierra-Madero et al, 2010). Efavirenz is also the key component of the most efficacious treatment cocktails, whether as a necessary add-on for widely prescribed combination drugs such as lamivudine/ zidovudine (Combivir) and tenofovir/emtricitabine (Truvada) or as a one pill formulation consisting of tenofovir/ emtricitabine/efavirenz (Atripla) (Gulick et al, 2004; Hammer et al, 2008). Although highly effective, a standard dose of efavirenz is known to carry a risk of side effects that include adverse neuropsychiatric complications such as depression, anxiety, sleep disturbances, impaired concentration, aggressive behavior, night terrors, hallucinations, paranoia, psychosis, "
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    • "In present treatment highly active antiretroviral therapy (HAART) (Tozser 2001) is utilized that involves combination therapy in which several different NRTIs, such as AZT and 3TC, are given at lower doses than in monotherapy, together with a viral protease inhibitor, such as ritonavir, in a drug cocktail. While the most recent international guidelines on AIDS therapy recommend tenofovir/emtricitabine or abacavir/lamivudine as the NRTIs of choice in the HAART regimen (Hammer et al. 2008), zidovudine is still routinely used in many settings and stavudine is still employed in some resource limited settings. While HAART has revolutionized AIDS treatment it is life-long and is still associated with a myriad of toxicities that vary according to the NRTIs used. "
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