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August 15, 2006
Updated Treatment Guidelines for Adult HIV (Reuters Health)
August 15, 2006 (Reuters Health) - The International AIDS
Society-USA Panel has released guidelines updating its treatment
recommendations for adult HIV infection, according to a report in the
August 16th issue of the Journal of the American Medical Association.
Lead author Dr. Scott M. Hammer, from Columbia University in New
York, presented the "consensus of a 17-member panel" on Sunday at a
JAMA media briefing held at the International AIDS Conference in
Toronto.
According to the report, the International AIDS Society-USA Panel
has updated its HIV treatment guidelines seven times since 1996, the
last being in 2004.
The current update was generated by a panel of individuals who were
appointed based on expertise in HIV research and patient care. In
creating the guidelines, the group evaluated data published or
presented from mid 2004 to May 2006. The focus was on data that could
actually alter the 2004 guidelines.
"We focused on the four classic questions of antiretroviral therapy:
when to start; what to start with; when to change -- because of
toxicity or poor response -- and what to change to," Dr. Hammer said.
The guidelines continue to recommend starting antiretroviral therapy
in all symptomatic patients and in asymptomatic patients whose CD4+
cell count has dropped below 350/µL and has not yet fallen below
200/µL, the researchers state.
The initial drug regimen should include either a nonnucleoside
reverse transcriptase inhibitor or a protease inhibitor boosted with
low-dose ritonavir. In addition, the patients should receive two
nucleoside reverse transcriptase inhibitors.
A change in therapy should occur whenever toxic effects or
intolerance require it. Such a change is also indicated in cases of
documented treatment failure.
What agent to change to depends on the reason for the change, the authors note.
If the change is due to toxic effects that can be clearly linked to
a particular agent, a single-drug substitution may suffice. Stopping
all drugs and reevaluating the situation may be necessary if the
toxicity cannot be tied to just one drug.
If the reason for change is treatment failure, then what to change
to depends on whether it is a first or multiple regimen failure. With
either type of failure, however, the goal is to make a change that
ensures at least two active agents are included in the regimen.
"Perhaps the biggest single issue that separates these guidelines
from the past is the redefinement of the goal of therapy in
treatment-experienced individuals -- particularly highly experienced
individuals," Dr. Hammer said. "In the past, we were satisfied to drop
viral load by half aa log to a log and to maintain immunologic and
clinical benefits," he said. Now a fair amount of individuals can
achieve undetectable viral levels, even patients with triple class
experience.
"Given the rapid evolution of knowledge, clinicians are challenged
to stay abreast of new information that can affect practice," the
authors conclude. "Therapeutic choices rooted in the pathogenesis of
HIV disease and individualization of therapy to maximize benefit are
the principles that remain constant in a rapidly changing environment."
