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: 35.29). 08/2008; 300(5):555-70. DOI: 10.1001/jama.300.5.555
Source: PubMed


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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    • "Developing countries like India with heavy burden of HIV-1 population has also seen a gradual increase in use of ART and at present 0.6 million individuals are taking 1st line ART [3]. In order to sustain the success of this ART program it is important to monitor the patients in regular interval and keep switching the treatment regimen [4] as per need of the patient. As HIV-1 drug resistance is one of the formidable causes for treatment failure and choice for drugs are limited, there is need for a cost effective HIV-1 drug resistance monitoring system in resource limited settings like India [5]. "
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    • "Drug intolerability has been cited as the main reason as to why patients either modify or discontinue regimen[7]–[14]. While this may be a global concern, the situation in affluent countries is bearable owing to the treatment options available [15]. This is in contrast to the situation in resource constrained settings where treatment regimens are limited and thus there are few options for patients experiencing drug intolerance [6]. "
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    • "Other consequences of ARV use include osteoporosis and avascular necrosis in bones, prostate neoplasia and lethal solid tumors such as non-Hodgkin lymphoma that are mostly associated with NNRTIs.60,61,62 Because of the side effects associated with many classes of ARVs, risk factors for cardiovascular disease, such as hypertension, hyperlipidemia, diabetes and tobacco use, should be aggressively managed in all patients.63,64 "
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